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.
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Related Questions
Correct Answer is D
Explanation
D. Petechiae, which are small red or purple spots caused by bleeding under the skin, are a classic manifestation of fat embolism syndrome. They typically appear on the upper chest, axilla (armpit), and conjunctiva of the eyes. Petechiae result from the occlusion of small blood vessels by fat globules, leading to microvascular bleeding.
A Paresthesia distal to the fracture site is not a typical manifestation of fat embolism syndrome. Instead, paresthesia may suggest nerve compression or injury related to the fracture itself rather than fat emboli.
B Fever is not a specific manifestation of fat embolism syndrome. While fever can occur with various types of infections or inflammatory conditions, it is not a hallmark symptom of fat embolism.
C Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), which is a potential complication of lower limb fractures. However, it is not a typical manifestation of fat embolism syndrome.
Correct Answer is B
Explanation
B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.
C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.
D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.
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