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1. A nurse is caring for a patient who has undergone a total hip
replacement. The nurse knows that the most common complication of this
surgery is:
a) Infection
b) Hemorrhage
c) Dislocation
d) Thromboembolism
Answer: c) Dislocation
Rationale: Dislocation of the prosthesis can occur if the hip is flexed more
than 90 degrees or if the leg is adducted or internally rotated. The nurse
should instruct the patient to avoid these movements and use an abduction
pillow or wedge to keep the legs apart.
2. A nurse is preparing to administer a blood transfusion to a patient who
has severe anemia. The nurse should perform which of the following
actions before starting the transfusion?
a) Check the patient's vital signs and compare them with the baseline
values
b) Obtain a written consent from the patient or a family member
c) Verify the blood type and Rh factor of the donor and the recipient
d) All of the above
Answer: d) All of the above
Rationale: The nurse should check the patient's vital signs and compare
them with the baseline values to detect any signs of transfusion reaction.
The nurse should also obtain a written consent from the patient or a family
member, as blood transfusion is an invasive procedure that carries some
risks. The nurse should also verify the blood type and Rh factor of the
donor and the recipient, as mismatched blood can cause hemolytic
reaction.
3. A nurse is assessing a patient who has a chest tube connected to a
water-seal drainage system. The nurse observes continuous bubbling in
the water-seal chamber. The nurse should interpret this finding as:
a) Normal
b) Indicating an air leak
c) Indicating fluid overload
d) Indicating infection
Answer: b) Indicating an air leak
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