A nurse is caring for a client who is postoperative following a total left hip arthroplasty. Which of the following actions should the nurse take?
Cross the client's legs when sitting in the recliner.
Provide a heating pad to the operative hip.
Place a pillow between the legs when turning the client to their side.
Have the client lean forward when assisting them out of the bed.
The Correct Answer is C
Choice A rationale:
The nurse should not cross the client's legs when sitting in the recliner following a total left hip arthroplasty. Crossing the legs can put strain on the operative hip and may increase the risk of dislocation or other complications.
Choice B rationale:
Providing a heating pad to the operative hip is not recommended. Heat can increase blood flow to the area and may lead to increased swelling and potential complications in the postoperative period.
Choice C rationale:
Placing a pillow between the legs when turning the client to their side is the correct action. This technique is known as the "abduction pillow”. or "wedge pillow.”. It helps maintain proper hip alignment and prevents the operated leg from crossing the midline, reducing the risk of dislocation and promoting healing.
Choice D rationale:
Having the client lean forward when assisting them out of the bed is not appropriate after a total left hip arthroplasty. Leaning forward can put strain on the hip joint and increase the risk of injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Severe headache can be a symptom of a subdural hematoma, but it is not the earliest manifestation of a change in neurological status. Other symptoms may appear before a severe headache, such as an altered level of consciousness.
Choice B rationale:
Bradycardia can occur with a subdural hematoma, especially as intracranial pressure increases. However, it is not the earliest manifestation of a change in neurological status. Changes in heart rate may occur later in the progression of the condition.
Choice C rationale:
Widened pulse pressure can also occur in patients with a subdural hematoma due to increased intracranial pressure. However, it is not the earliest manifestation of a change in neurological status. Other neurological signs would likely appear before changes in pulse pressure are evident.
Choice D rationale:
Change in level of consciousness is the earliest manifestation of a change in neurological status with a subdural hematoma. As intracranial pressure increases, the brain's functioning can be affected, leading to alterations in consciousness, ranging from mild confusion to unconsciousness.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale:
An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.
Choice B rationale:
Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.
Choice C rationale:
Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.
Choice D rationale:
Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.
Choice E rationale:
Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.
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