The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

Correct Answer: D

Rationale: The correct answer is D) Perform neurovascular assessments per protocol. In the context of a post-operative client after a total hip arthroplasty, monitoring neurovascular status is crucial to assess for any signs of compromised circulation or nerve function. This intervention is a priority as it helps in early detection of complications such as compartment syndrome, deep vein thrombosis, or nerve damage, which can have serious implications if not addressed promptly. Option A) Observing client for changes in mental status, while important, is not the priority in this scenario as neurovascular compromise poses a more immediate threat to the client's physical well-being. Option B) Using aseptic technique for wound care and emptying of drains is important for infection prevention, but it is not the priority over monitoring neurovascular status. Option C) Keeping the client's heels off the bed is aimed at preventing pressure ulcers and maintaining skin integrity, which is also important but not the priority when compared to assessing neurovascular status. Educationally, this question highlights the critical thinking skills required in prioritizing nursing interventions based on the client's condition and the potential risks involved. It underscores the importance of timely and accurate assessments in post-operative care to ensure optimal patient outcomes.

Correct Answer: D

Rationale: In the case of a patient with COPD receiving supplemental oxygen at 2 L/min via nasal cannula, the most appropriate positioning technique to assist with breathing is Fowler's position (Option D). Fowler's position involves sitting upright with the upper body elevated at a 45-90 degree angle. This position helps improve lung expansion, making it easier for the patient to breathe by allowing the diaphragm to move more effectively and reducing pressure on the lungs. The other options are not as suitable for a patient with COPD needing assistance with breathing. Prone position (Option A) involves lying flat on the stomach, which can limit lung expansion and make breathing more difficult. Sim's position (Option B) is a side-lying position typically used for procedures involving the rectal area and does not provide the same benefits for respiratory function. Lateral position (Option C) is lying on the side, which also does not facilitate optimal lung expansion compared to Fowler's position. Educationally, understanding the rationale behind positioning techniques for patients with respiratory conditions like COPD is crucial for healthcare providers. Fowler's position is a fundamental concept in nursing and respiratory care, as it can significantly impact a patient's breathing ability and overall comfort. By selecting the appropriate positioning technique, healthcare professionals can effectively support patients in managing their respiratory conditions and improving oxygenation levels.

Correct Answer: A

Rationale: In the context of wound healing, the correct answer is A) Fistula. A fistula is an abnormal passage that connects two body cavities or a cavity and the skin. This complication can occur as a result of poorly healing wounds or surgical procedures. Option B) Hemorrhage refers to excessive bleeding, which is not related to the formation of abnormal passages between body structures. Option C) Evisceration is the protrusion of internal organs through a surgical incision or wound, not the formation of a passage between body structures. Option D) Infection is the invasion and multiplication of microorganisms in body tissues, which can impede wound healing, but it does not involve the creation of abnormal passages. Understanding these distinctions is crucial for healthcare professionals involved in wound care and postoperative management. Recognizing the complications of wound healing allows for timely intervention and prevention of further issues, ultimately improving patient outcomes and reducing the risk of complications post-surgery.

Correct Answer: C

Rationale: The most appropriate statement by the nurse is option C: "Please tell me more about when your pain started." This response demonstrates effective communication and patient-centered care. By asking the client to elaborate on when the pain started, the nurse shows empathy, gathers essential information for assessment, and opens the door for the client to express their concerns fully. Option A is incorrect because it dismisses the client's symptoms without further assessment or a holistic approach to care. Option B is incorrect as it provides a premature diagnosis without proper evaluation. Option D is incorrect as it oversimplifies the issue by solely focusing on weight without addressing the underlying cause of the symptoms. In an educational context, this question highlights the importance of active listening, open-ended questioning, and patient assessment in nursing practice. It emphasizes the need for nurses to gather comprehensive information, consider differential diagnoses, and approach patient care with empathy and a holistic perspective. Effective communication skills are essential in building trust, understanding patient needs, and providing quality care.

Correct Answer: B

Rationale: In this scenario, the nurse would suspect deep vein thrombosis (DVT) due to the client's symptoms of a hot, red, and painful leg. DVT occurs when a blood clot forms in a deep vein, commonly in the legs. Prolonged bed rest, as in the case of the client with systemic sclerosis, can increase the risk of DVT due to reduced blood flow and pooling of blood in the veins. The symptoms described are classic signs of DVT, indicating a potential clot that requires immediate medical attention to prevent serious complications like pulmonary embolism. Regarding the other options: A) Amputation: There is no indication in the scenario to suggest the need for amputation. C) Internal bleeding: The symptoms described do not align with those of internal bleeding. D) Kidney failure: The symptoms presented are not characteristic of kidney failure. Educationally, it is crucial for nurses to recognize the signs and symptoms of DVT, especially in clients who are immobile or have underlying conditions that predispose them to clot formation. Early detection and intervention are essential to prevent complications and provide appropriate care for the client. Understanding the risk factors, symptoms, and management of DVT is essential for nurses to deliver safe and effective patient care.