A nurse is caring for a client who had total hip arthroplasty 2 days ago. Which of the following actions should the nurse take

Instruct the client to bend at the waist to put on slippers

Keep the client's heels elevated while in bed

Massage the clients affected leg three times daily

Maintain slight adduction of the client's affected hip

Answer and Explanation

The Correct Answer is D

Rationale:

A. Instruct the client to bend at the waist to put on slippers: Bending at the waist increases the risk of hip dislocation after total hip arthroplasty. Clients should avoid flexing the hip beyond 90 degrees and use adaptive equipment for dressing to maintain safety.

B. Keep the client's heels elevated while in bed: Elevating the heels is not routinely indicated and may cause hip or knee strain. Proper positioning focuses on maintaining hip alignment and preventing dislocation or pressure injuries rather than heel elevation.

C. Massage the client’s affected leg three times daily: Massaging the leg after hip surgery is contraindicated due to the risk of dislodging a deep vein thrombus (DVT). Gentle range-of-motion exercises are preferred, but direct massage should be avoided until clotting risk is ruled out.

D. Maintain slight abduction of the client’s affected hip: Keeping the hip in slight abduction with pillows or abduction devices helps prevent dislocation of the prosthetic joint. Proper positioning is essential for safe recovery following total hip arthroplasty.

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Correct Answer is C

Explanation

Rationale:

A. Fidelity: Fidelity refers to being faithful to commitments and maintaining trust in professional relationships. While important in nursing, it does not specifically relate to equitable distribution of community resources.

B. Autonomy: Autonomy emphasizes respecting an individual’s right to make informed decisions about their own care. Planning a program to ensure equal access addresses fairness, not individual decision-making.

C. Justice: Justice involves fairness in the distribution of resources, benefits, and risks. By ensuring prenatal resources are equally available to all community members, the nurse is practicing the ethical principle of justice and promoting equity in healthcare access.

D. Nonmaleficence: Nonmaleficence focuses on preventing harm to clients. While relevant to all nursing practice, it is not the primary principle guiding equitable allocation of prenatal resources in the community.

A. Remove the client's catheter. B. Prepare the client for chest tube insertion. C. Place the client in a left-lateral Trendelenburg position D. Instruct the client to perform the Valsalva maneuver.

Correct Answer is C

Explanation

Rationale:

A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.

B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.

C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.

D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.

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A nurse is caring for a client who had total hip arthroplasty 2 days ago. Which of the following actions should the nurse take

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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