A nurse is caring for a client who had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?
Encourage use of elastic stockings.
Monitor for shortening of the affected leg.
Avoid flexing the hips more than 60°.
Maintain foam wedge between legs.
The Correct Answer is D
A. Encouraging the use of elastic stockings is important for preventing deep vein thrombosis (DVT) postoperatively but does not directly prevent hip dislocation.
B. Monitoring for shortening of the affected leg is important to assess for complications such as dislocation or nerve injury, but it is not a preventive measure.
C. Avoiding flexion of the hips more than 60° is important to prevent dislocation, but the recommended limit is usually 90°, not 60°. It is crucial to keep the hip in an appropriate position to avoid excessive movement.
D. Maintaining a foam wedge between the legs is the most effective intervention to prevent hip dislocation. The wedge keeps the hips in proper alignment and prevents excessive internal rotation or adduction, which are common causes of dislocation after hip arthroplasty.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A cone-shaped dressing is a common and appropriate finding following an amputation. The dressing is typically shaped this way to help with the formation of a residual limb that is appropriately shaped for a prosthetic.
B. Pitting edema around the stump dressing is a complication. This could indicate poor circulation, infection, or fluid retention, which requires prompt assessment and intervention to prevent further complications.
C. Looseness of the stump dressing could be problematic, but it is not necessarily an immediate complication. It may lead to issues like infection or improper healing if not addressed, but it is not the most concerning finding in this scenario.
D. Figure-eight wrapping is a standard technique used to secure the dressing and promote proper shaping of the stump. It is an appropriate practice for amputation care.
Correct Answer is D
Explanation
A. Temperature is not directly used in the calculation of cardiac output. While fever can affect heart rate and cardiac output, it is not a primary factor in the calculation.
B. Respiratory rate is important for assessing overall respiratory status, but it is not a direct factor in calculating cardiac output.
C. Blood pressure is a useful measure of circulatory function but does not directly contribute to the calculation of cardiac output. Blood pressure is influenced by cardiac output, but it is not a component in its calculation.
D. Heart rate is one of the key components in calculating cardiac output, along with stroke volume. Cardiac output is calculated by multiplying the heart rate (beats per minute) by the stroke volume (the amount of blood pumped by the heart per beat). This provides the total amount of blood the heart pumps per minute.
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