A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position.
Which of the following actions is appropriate to prevent hip dislocation?
Place a wedge pillow between the legs.
Place a footboard on the bed.
Place a sandbag to the lateral calf.
Place a trochanter roll against the thigh.
The Correct Answer is A
After a total hip arthroplasty, it is important to prevent hip dislocation. One way to do this is to place a wedge pillow between the legs. This helps to keep the hip in a stable position and prevents the hip from moving too much, which could lead to dislocation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Sorbitol is a type of sugar alcohol used as a sweetener in many diet foods. It is also used in certain medications as a laxative to relieve constipation. However, it is not typically associated with liver failure and would not likely be questioned by the nurse in this context.
Choice B rationale
Lactulose is a type of sugar that is broken down in the large intestine into mild acids that draw water into the intestine, which then helps soften the stools. It is often used to treat constipation and is also used to reduce high blood ammonia levels in patients with liver disease. It would not typically be questioned by the nurse for a patient with chronic liver failure.
Choice C rationale
Neomycin is an antibiotic that is used to reduce the amount of ammonia produced by bacteria in the intestines. High levels of ammonia can cause hepatic encephalopathy, a serious complication of liver disease. Therefore, neomycin can be beneficial for patients with chronic liver failure and would not likely be questioned by the nurse.
Choice D rationale
Acetaminophen, also known as paracetamol, is a common over-the-counter medication used to relieve pain and reduce fever. However, high doses or long-term use of acetaminophen can cause liver damage. In fact, acetaminophen overdose is a common cause of acute liver failure. Therefore, the nurse should question an order for acetaminophen for a patient with chronic liver failure.
Correct Answer is A
Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
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