A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
Keep an abduction pillow between the client's legs.
Elevate the client's affected leg on a pillow when in bed.
Position the client's knees slightly higher than the hips when up in a chair.
Raise the head of the client's bed to a high-Fowler's position.
The Correct Answer is A
Choice A rationale:
Keeping an abduction pillow between the client's legs is a preventive measure to avoid dislocation of the hip prosthesis. This positioning helps maintain the correct alignment of the hip joint, reducing the risk of dislocation. Abduction pillows are commonly used postoperatively after total hip arthroplasty to support proper hip positioning while the patient is in bed.
Choice B rationale:
Elevating the client's affected leg on a pillow when in bed is not recommended after total hip arthroplasty. This position could lead to hip adduction, increasing the risk of prosthesis dislocation. Maintaining abduction (spreading the legs apart) is the key to preventing dislocation, and elevation should be avoided to maintain proper alignment.
Choice C rationale:
Positioning the client's knees slightly higher than the hips when up in a chair is not an appropriate preventive measure for prosthesis dislocation. Proper alignment is crucial, and the client should avoid sitting in low chairs or on low surfaces that could cause the hips to be lower than the knees, potentially leading to dislocation.
Choice D rationale:
Raising the head of the client's bed to a high-Fowler's position is unrelated to preventing prosthesis dislocation. Fowler's position refers to elevating the head of the bed to assist with breathing and facilitate patient comfort. While this position might be suitable for certain respiratory conditions, it has no direct impact on the stability of a hip prosthesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
Correct Answer is C
Explanation
Choice A rationale:
Allowing the client to have time alone in their room might provide some relief, but it does not address the caregiver's overall stress and the impact on their life. Moreover, constant isolation is not a healthy solution for the client, as social interaction is essential for their well-being.
Choice B rationale:
Discussing methods of communication with the client about resolving problem behaviors is a helpful approach. Effective communication strategies can reduce misunderstandings and challenging behaviors, easing the burden on the caregiver. This choice demonstrates a proactive approach to improving the caregiver's situation.
Choice C rationale:
Assisting the caregiver in arranging for a daycare program for the client is an excellent solution. Adult daycare programs provide a safe and stimulating environment for individuals with Alzheimer's disease, allowing caregivers to have some respite while ensuring the well-being of their loved ones. This choice addresses both the client's needs and the caregiver's stress, making it the most appropriate option.
Choice D rationale:
Suggesting that the caregiver seek a prescription for an antipsychotic medication for the client is not the best course of action without a thorough evaluation by a healthcare provider. Antipsychotic medications have side effects and are typically prescribed based on the client's specific symptoms and needs. Additionally, prescribing medications is beyond the nurse's scope of practice and should be determined by a healthcare provider after a comprehensive assessment.
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