Med Surg Quiz 5

a nurse if caring for a client who had a total hip replacement what nursing action should be incorporated into the plan of care to prevent thrombus formation? a. turning the client from side to side b. encouraging the client to perform ankle exercises c. getting the client up to sit in a chair for as long as tolerated d. ambulating the client when the effects of anesthesia subside

B

a nurse is caring for a client who had a total hip replacement. what is the priority assessment when monitoring the client for hemorrhage? a. checking vital signs every 4 hours b. examining the bedding under the client c. measuring the circumference of the thigh d. observing for ecchymosis at the operative site

B

a patient is reluctant to consider hip surgery because of a fear of blood transfusion reaction. what is the nurses best response? a. no one will force you to receive blood if you don't want it b. a cell saver can be used to collect your own red blood cells during surgery c. it's unlikely that you will need a blood transfusion please don't worry d. blood products are very safe these days and there are numerous safety protocols

B

a client has a total hip arthroplasty. what should the nurse do when caring for this client after surgery? a. use a pillow to keep the legs abducted b. elevate the clients affect limb on a pillow c. turn the client using the log rolling technique d. place a trochanter roll along the entire extremity

A

a client has a total knee replacement and a continuous passive motion device is being used. the nurse concludes that the teaching was effective when the client states the goal of the therapy is to: a. improve joint flexion b. maintain muscle tone c. prevent tissue breakdown d. avoid formation of a blood clot

A

a nurse recieves a change of shift report for a client who had a total hip replacement 24 hours ago. after reviewing the client's clinical record and completing a physical assessment which complication should the nurse conclude that the client is experiencing? a. fat embolism b. urinary retention c. hypovolemic shock d. pulmonary embolism

A

the nurse assesses the patients surgical hip site and measures the drainage every 4 hours. at 7 am there is 30 mL in the drainage container. at 11 am there is 10 mL; at 3 pm there is 5 mL and at 7 pm there is 20 mL. what should the nurse do? a. document the drainage and continue to observe the site and drainage every 4 hours b. take vital signs, observe the site for signs of hemorrhage, and notify the surgeon c. document the findings but change the assessment frequency to every 2 hours d. ask the patient if there is increased pain or decreased sensation on the affected side

A

the nurse is caring for a patient who had a total joint replacement and administers sub q enoxaparin as ordered. which outcome statement indicates that the intended goal of the enoxaparin therapy is being met? a. patient does not show signs or symptoms of venous thromboembolism b. prothombin time and INR are within normal range c. pain is rated at a 3/10 within 30 minutes after receiving the medication d. wound site is free of infection signs and oral temp is 98.8

A

the nurse is supervising a student in the post op care of a patient who had a total knee replacement and has a continuous passive motion device. when would the nurse intervene? a. student applies hot moist compresses to the incisional area b. student turns of the CPM while the patient is having a meal in bed c. student places a cloth between the skin of the incisional area and ice packs d. student checks to see that the CPM is well padded to protect the skin

A

when a client is in the right side lying position after the insertion of a left hip prosthesis the nurse ensures that the client has a pillow placed between the thighs and that the entire length of the upper leg is supported. what does this pillow prevent? a. strain on the operative site b. thrombus formation in the leg c. flexion contractures of the hip joint d. skin surfaces from rubbing together

A

which intervention does the nurse implement to improve mobility for a patient who has undergone a total hip replacement? a. encourage the use of assistive devices such as a walker when ambulating b. recommend to quickly decrease rest period between activities c.instruct to flex and extend the hips at least 90 degrees when doing leg exercises d. advice to progressively put more weight on the affected side

A

which patient circumstance would be considered contraindication for total joint arthroplasty? a. patient is currently being treated for a persistent urinary tract infection b. patient reports pain and loss of mobility related to joint dysfunction c. patient reports her osteopenia is now considered to be osteoporosis d. patient is elderly and has no one to provide post op care

A

following a total joint arthroplasty which patients have a higher risk of venous thromboembolism? Select all a. older patient who has trouble with mobility at baseline b. obese patient with chronic pain associated with RA c. patient with a previous history of VTE related to jobs as a truck driver d. thin patient who needs medication for hyperthyroidism e. patient with compromised circulation secondary to sickle cell disorder f. patient with a history of osteoarthritis pain that is treated with acetaminophen

A B C E

which interventions can the nurse use to prevent or manage infections in patients who have undergone total joint replacement? select all a. use aseptic technique for wound care and emptying of drains b. wash hands thoroughly when caring for patients c. culture drainage fluid if a change is observed d. encourage early ambulation alone with leg exercises e. monitor the incision every 4 hours for the first 24 hours and every 8-12 hours thereafter f. advocate that the patient be placed in a private isolation room

A B C E

for preoperative care of a patient scheduled for a total joint arthroplasty what does the nurse plan to do? select all a. provide written or videotaped information about the procedure b. assess the patients understanding of the procedure c. assess and include the patients support people or family d. obtain the patients signature on the consent form e. assist in scheduling needed dental procedures after the surgery f. include interdisciplinary team members if possible

A B C F

the nurse assesses a post op patient who had a total knee replacement for neurovascular compromise. which assessments must the nurse document? select all a. skin color and temperature b. presence or absence of distal peripheral pulses c. full range of motion for operative and nonoperative legs d. capillary refill of operative leg e. comparison of operative leg to nonoperative leg f. ability to use extremity compared to baseline

A B D E

which routine interventions would the nurse perform to prevent the life-threatening complication of venous thromboembolism? select all a. ensure that sequential compression device is in place and functional b. administer anticoagulant therapy as ordered c. roll and secure top of antiembolic d. encourage early ambulation e. teach patient about leg exercises f. encourage foods that are rich in iron and protein

A B D E

every 2-4 hours the nurse assesses a patient who has a continuous femoral nerve blockade for post op pain management following a knee joint replacement. what findings prompt the nurse to alert the surgeon about untoward systemic effects of the local anesthesia? a. patient is unable to detect pain with plantar flexion of the affected foot b. patient reports metallic taste, tinnitus, and a nervous feeling c. patient says that the affected foot feels warmer than the unaffected foot d. patient reports nausea and mild abdominal discomfort

B

a patient is on anticoagulant therapy with dalteparin after total joint arthroplasty. which laboratory test should the nurse monitor? a. prothrombin time and INR b. oxygen saturation and liver enzymes c. CBC and platelet count d. erythrocyte sedimentation rate and c reactive protein

C

the nurse is caring for a post op patient with a hip replacement. which patient care actions can be delegated to the experienced UAP? select all a. inspect heels and other bony prominences every 8 hours b. turn and reposition the patient every 2 hours c. assure that the patients heels are elevated off the bed d. assess the patients calf regions for redness and swelling e. check vital signs and oxygen saturation via pulse oximetry f. assess for pain and administer pain medication

B C E

a client has a total hip replacement. which clinical indicators of pulmonary embolism indicate that the plan to prevent post op thrombus formation has been ineffective? select all a. flushing of the face b. unilateral chest pain c. elevation of temperature d. sudden onset od SOB e. pain rating increase from 2 to 8 in the hip

B D

a nurse provides discharge teaching for a client who had a total hip replacement. which activities to avoid identified by the client indicate an understanding of the teaching? select all a. climbing stairs b. crossing the legs c. stretching exercises d. sitting in a low chair e. lying prone for 30 minutes

B D

a client is ready to walk with crutches after knee surgery. which crutch walking technique will the nurse most likely have to reinforce after the client returns from physical therapy? a. two point b. four point c. three point d. swing through

C

a nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. on which part of the body should the nurse instruct the client to place weight? a. the upper arms b. the axillary region c. palms of the hands d. both lower extremities

C

a patient is post op for a total hip arthroplasty and needs to get out of bed for the first time. what should the nurse do? a. schedule an appointment with physical therapy and wait for the therapist to assist the patient b. caution UAP about fall prevention and instruct to observe for dizziness c. put a gait belt on the patient and stand on the same side of the bed as the affected leg d. ask the patient how much assistance is needed to stand and pivot into the chair

C

a patient with RA may need to undergo general anesthesia for a hip replacement. which information needs to be brought to the immediate attention of the surgeon before the procedure is scheduled? a. patient has a previous history of joint surgery on the affected side b. patient has been taking vitamin C and NSAID drugs for years c. patient has cervical spine disease and has not had any recent spinal x rays d. patient fears that the procedure will cause complications because of the RA

C

the nurse is providing care for a patient scheduled for a total hip arthroplasty. which medication should the patient receive one hour before the surgical incision in accordance with the surgical care improvement project core measures? a. low-molecular weight heparin, such as subcutaneous enoxaparin b. fast-acting opioid such as IV morphine c. broad spectrum antibiotic such as IV cefazolin d. routine daily dose of oral antihypertensive

C

what is an important health teaching point for a patient with total joint arthroplasty? a. do not use the joint b. stress the joint c. protect the joint d. guard the muscles

C

when educating a patient about total joint arthroplasty what does the nurse do first? a. ensure that the patient wants the procedure b. review instructions and ask the patient to repeat back c. assess the patient's knowledge about TJA d. ask if the provider has explained the procedure

C

which outcome statement indicates that the therapeutic goal of continuous passive motion therapy is being met? a. patient has no signs or symptoms of VTE b. stress and strain on the knee joint are reduced c. mobility of the patients prosthetic knee is maintained d. patient uses the CPM device while ambulating

C

which position should a nurse avoid placeing a client who had surgery for a total hip replacement? a. supine b. lateral c. orthopneic d. semi-fowler

C

on the first postop day after a total hip replacement a client asks for assistance onto the bedpan. what should the nurse instruct the client to do? a. use the elbows and hands to lift the pelvis off the bed b. extend both legs and pull on the trapeze to lift the pelvis c. turn gently toward the operative side while lifting the pelvis off of the bed d. flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis

D

the nurse is caring for a patient who had a total hip replacement. on assessment the nurse observes shortening of the affected leg and internal rotation. the patient reports increased pain that is not relieved with medication. what should the nurse do? a. conduct additional pain assessment and obtain new medication orders b. position the leg in an anatomical position and place pillows for support c. compare the length of the affected leg to the unaffected leg d. keep the patient in bed and immediately notify the surgeon

D

to prevent VTE several types of anticoagulant medications can be ordered. Which drug is most commonly used during hospitalization? a. oral or parenteral aspirin b. oral warfarin c. intravenous tissue plasminogen activator d. subcutaneous low molecular weight heparin

D