Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
17. A nursing student is assigned to care for a client who is 2 days post–total left hip replacement. Which observation should be reported immediately to a staff nurse?
. Pain rated as 5 on a scale of 0–10.
. Temperature, 99.6°F; reddened incision.
. Pain and cramping in the right lower leg.
. Difficulty tolerating weight-bearing on the left leg.
Test-Taking Tip
When all options are important nursing concerns, look for the one where an immediate response could prevent a serious consequence.
Content Area: Adult Health, Musculoskeletal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because this is not unexpected following surgery. If the client were unresponsive to pain medication, there might be a greater concern. Answer 2 is correct because an infection following hip replacement is a serious complication that may require removal of the implant. Total joint infections may be disastrous, with prevention of an infection a priority. Usually prophylactic antibiotics are ordered; therefore, the appearance of a wound infection would be a grave concern. Answer 3 is incorrect because a deep vein thrombosis (DVT) would not be expected until 5 to 7 days after surgery. DVTs do occur in 45% to 70% of clients after hip surgery. Further assessment would be needed, such as the presence of a positive Homans' sign and calf swelling. Answer 4 is incorrect because the ability to tolerate weight-bearing varies with the client's condition, the procedure done, and the type of fixation device used. There is insufficient information to know if this is a problem.