A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?
Teach the client which positions to avoid during PT.
Identify the client's pain level and medicate if needed.
Perform the client's morning care.
Encourage the client to use full weight bearing.
The Correct Answer is B
B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.
A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.
C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.
D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Repositioning the client regularly is an important intervention to prevent pressure ulcers and pressure points, especially when the client is immobilized in traction. Repositioning helps distribute pressure evenly on different areas of the body, reducing the risk of tissue ischemia and pressure-related injuries around the edges of the splint.
A. Lotions or moisturizers can increase the risk of skin breakdown and infection, especially when applied under medical devices such as splints or casts.
C. Removing the weights for a few minutes each hour is not necessary to prevent pressure points around the edges of the splint. Balanced skeletal traction is typically applied to maintain continuous traction force on the fractured femur for therapeutic purposes.
D. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint. Foot plates are typically used to prevent foot drop and maintain proper alignment of the foot and ankle joints.
Correct Answer is A
Explanation
A. Checking capillary refill distal to the cast helps assess peripheral circulation and nerve function. A decrease in capillary refill time or other signs of compromised circulation (such as coolness, pallor, or numbness) could indicate a complication like compartment syndrome, which requires immediate intervention.
B. Performing range of motion exercises is important for promoting joint mobility and preventing stiffness, but it is not the priority immediately after the cast application.
C. Educating the client about cast care is important for promoting healing and preventing complications, but it is not the priority immediately after the cast application.
D. Managing pain is important for the client's comfort and well-being, but it is not the priority immediately after the cast application.
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