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. Obtaining a blood sample is important for diagnosing a myocardial infarction, but it is not the immediate priority. The nurse should first focus on stabilizing the patient before performing diagnostic tests.
B. Initiating oxygen therapy is the priority action. Oxygen is critical in improving oxygenation and reducing myocardial stress during a myocardial infarction. It helps prevent further damage to the heart muscle and supports overall cardiac function.
C. Inserting the IV catheter is important for administering medications and fluids, but it is not as urgent as providing oxygen therapy, which directly impacts the client's oxygenation and cardiac function.
D. Attaching the leads for a 12-lead ECG is essential for diagnosing a myocardial infarction, but the priority is to stabilize the patient by administering oxygen before performing diagnostic tests.
Correct Answer is B
Explanation
A. Ensuring adequate nutrition is important, but the priority is preventing aspiration, as the client may have difficulty swallowing or clearing the airway due to the intermaxillary fixation. Aspiration could lead to serious complications like pneumonia.
B. Preventing aspiration is the priority because the client may have difficulty swallowing or controlling their airway due to the surgical procedure and fixation of the jaw. The nurse should ensure the client's airway is clear and that they are positioned appropriately to prevent aspiration.
C. Pain relief is important for comfort and recovery, but it is secondary to ensuring the client's airway is protected and preventing aspiration, which could lead to more severe complications.
D. Promoting oral hygiene is important, but it is not the priority in the immediate postoperative period. The focus should be on ensuring the airway is clear and preventing aspiration, especially if the client is unable to properly swallow or manage secretions.
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