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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Ecchymosis (bruising) of the surrounding skin is a common finding in fractures and is related to bleeding under the skin. While it is a sign of trauma, it does not specifically indicate impaired venous return.
B. Increasing edema is a key sign of impaired venous return. When the veins are not effectively draining blood, fluid accumulates in the tissues, causing swelling. This is a critical sign of venous insufficiency or compromised circulation.
C. Acute pain is a common symptom of fractures, but it is not directly related to impaired venous return. Pain is typically associated with the injury itself, not with circulatory issues.
D. An abounding distal pulse suggests that blood is still flowing to the affected area, indicating that arterial circulation is intact. Impaired venous return typically does not affect the pulse directly but rather causes swelling and other signs of venous congestion.

A. Encourage the client to ambulate frequently. B. Encourage coughing and deep breathing. C. Encourage the client to increase fluid intake. D. Encourage regular use of the incentive spirometer.

Correct Answer is C

Explanation

A. Encouraging ambulation can help improve overall lung function and circulation, but it is not directly related to thinning respiratory secretions.
B. Coughing and deep breathing can help mobilize secretions, but they do not directly thin the secretions. This is more about clearing the airways.
C. Increasing fluid intake is the most effective way to thin respiratory secretions. Fluids help to hydrate the mucous membranes, making the mucus less thick and easier to clear.
D. The incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis, but it does not directly thin respiratory secretions.

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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?

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