A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

Place a trochanter roll against the thigh.

Place a sandbag to the lateral calf.

Place a wedge pillow between the legs.

Place a footboard on the bed.

Answer and Explanation

The Correct Answer is C

An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.

Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent the external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar ﬂexion contractures.

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Correct Answer is C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

A. Apply heat to the area of swelling for the first 48 hr. B. Repeatedly ask the client questions to check for orientation. C. Do not let the client engage in strenuous activities for 1 week. D. Encourage the client to sleep for the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.

Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inﬂammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.

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A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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