A nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
Perform range of motion by adducting the hip.
Sit in a straight-backed chair.
Cleanse the surgical incision with hydrogen peroxide.
Apply moist heat to the incision while in bed.
The Correct Answer is B
Choice A reason: Performing range of motion by adducting the hip is an incorrect instruction for a client who had a total hip arthroplasty. Adduction is moving the leg toward the midline of the body, which can cause dislocation of the prosthesis. The nurse should instruct the client to perform range of motion by abducting (moving away from midline), flexing (bending), and extending (straightening) the hip as prescribed by physical therapy.
Choice B reason: Sitting in a straight-backed chair is a correct instruction for a client who had a total hip arthroplasty. This position helps to maintain proper alignment and stability of the hip joint and prevents excessive flexion or rotation that can cause dislocation. The nurse should also instruct the client to avoid crossing legs, bending forward more than 90 degrees, or twisting at the waist.
Choice C reason: Cleansing the surgical incision with hydrogen peroxide is an incorrect instruction for a client who had a total hip arthroplasty. Hydrogen peroxide is a harsh agent that can damage healthy tissue and delay healing. The nurse should instruct the client to cleanse the incision with mild soap and water or as directed by the provider and keep it dry and covered with sterile dressing.
Choice D reason: Applying moist heat to the incision while in bed is an incorrect instruction for a client who had a total hip arthroplasty. Moist heat can increase swelling, inflammation, and infection risk at the incision site. The nurse should instruct the client to apply ice packs or cold compresses to the incision as needed to reduce pain and swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: This is not an expected finding for a client who has cystitis because pruritus or itching is not a common symptom of urinary tract infection or inflammation of the bladder. The nurse should assess for other causes of pruritus, such as skin disorders, allergies, or parasites.
Choice B reason: This is not an expected finding for a client who has cystitis because bradycardia or slow heart rate is not a common symptom of urinary tract infection or inflammation of the bladder. The nurse should assess for other causes of bradycardia, such as medication side effects, cardiac disorders, or electrolyte imbalances.
Choice C reason: This is an expected finding for a client who has cystitis because hematuria or blood in urine is a common symptom of urinary tract infection or inflammation of the bladder. The nurse should collect urine samples for urinalysis and culture and sensitivity tests and administer antibiotics as prescribed.
Choice D reason: This is an expected finding for a client who has cystitis because confusion or altered mental status is a common symptom of urinary tract infection or inflammation of the bladder in older adults. The nurse should monitor the client's level of consciousness and orientation and provide safety measures and education as needed.
Choice E reason: This is an expected finding for a client who has cystitis because dysuria or painful urination is a common symptom of urinary tract infection or inflammation of the bladder. The nurse should encourage oral fluid intake and cranberry juice or supplements and administer analgesics as prescribed.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because auscultating the client's abdomen for bowel sounds is an assessment that can provide information about the client's bowel motility and function. The nurse should listen for at least 5 minutes in each quadrant and note the frequency, intensity, and quality of bowel sounds.
Choice B reason: This is not an appropriate action to take first because providing privacy with a set time to defecate is an intervention that can promote regular bowel elimination and prevent constipation. The nurse should perform this action after assessing the client's bowel sounds and other factors that may affect defecation, such as pain, medication, diet, and activity.
Choice C reason: This is not an appropriate action to take first because encouraging oral intake of fluids is an intervention that can soften stool and facilitate bowel movement. The nurse should perform this action after assessing the client's bowel sounds and fluid balance status.
Choice D reason: This is not an appropriate action to take first because administering a fiber-based laxative is an intervention that can increase bulk and stimulate peristalsis. The nurse should perform this action after assessing the client's bowel sounds and contraindications for laxatives, such as bowel obstruction, impaction, or perforation.
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