a nurse is caring for a client who is 2 hr postoperative following a total hip arthroplasty which of the following actions should the nurse take

ATI RN

ATI Comprehensive Exit Exam

1. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

A. Position the client supine with a pillow between the legs.
B. Place an abduction pillow between the client's legs.
C. Place a pillow under the client's knees.
D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

2. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

A. INR 1.8
B. Hemoglobin 14 g/dL
C. Platelets 175,000/mm³
D. Potassium 3.8 mEq/L

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

3. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.

4. How should signs of infection in a post-surgical patient be assessed?

A. Check the surgical site
B. Check the patient's vital signs
C. Monitor for fever
D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

5. What is the first action to take for a patient experiencing a seizure?

A. Administer anticonvulsant medication
B. Protect the patient's head
C. Insert an oral airway
D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.