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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Reporting any worsening or unrelieved pain is important because increasing or unrelieved pain could indicate complications such as inadequate immobilization, pressure sores, or compartment syndrome. Prompt reporting allows for timely intervention and prevention of further complications

B. Movement of the affected leg could disrupt the alignment of the bones and impede the healing process. Immobilization is essential for bone healing in a fiberglass cast. However, reporting features of compartment syndrome is priority.

C. Patients should be advised not to insert anything under the cast and instead use other methods such as blowing cool air under the cast or gently tapping on the outside of the cast to relieve itching.

D. Using a blow dryer on a moderate heat setting can help speed up the drying process of the cast after it gets wet. However, it's important to ensure that the heat is not too high to avoid causing burns or softening the cast material excessively.

A. The patient reports abdominal pain when ambulating. B. The patient has fluid intake 600 mL greater than the output. C. The patient's calf is swollen and warm to touch. D. The patient's temperature is 100.3° F (37.9° C).

Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

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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?

Nursing Test Bank

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Correct Answer is C

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