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 A
Explanation
Choice A reason: This is an indication that the client needs further testing because a palpable area of induration, greater than 10 mm (0.4 in) in diameter, is considered a positive result for the tuberculin skin test, which means that the client has been exposed to Mycobacterium tuberculosis and may have latent or active tuberculosis infection. The nurse should refer the client for chest x-ray and sputum culture and sensitivity tests to confirm the diagnosis and rule out other conditions.
Choice B reason: This is not an indication that the client needs further testing because an area of ecchymosis, greater than 12 mm (0.5 in) in diameter, is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and monitor the site for any signs of infection or inflammation.
Choice C reason: This is not an indication that the client needs further testing because tenderness at the injection site is not considered a positive result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and provide comfort measures as needed.
Choice D reason: This is not an indication that the client needs further testing because a nonpalpable area of redness, less than 5 mm (0.2 in) in diameter, is considered a negative result for the tuberculin skin test, which means that the client has not been exposed to Mycobacterium tuberculosis and does not have latent or active tuberculosis infection. The nurse should document the finding and educate the client about tuberculosis prevention and screening recommendations.
Correct Answer is D
Explanation
Choice A reason: This is not an immunization that the nurse should identify as needed for this client because measles, mumps, and rubella are viral diseases that can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice B reason: This is not an immunization that the nurse should identify as needed for this client because human papilloma virus is a sexually transmitted infection that can cause genital warts or cervical cancer and can be prevented by vaccination before sexual activity or exposure. The nurse should educate the client about safe sex practices and screening tests for cervical cancer.
Choice C reason: This is not an immunization that the nurse should identify as needed for this client because inactivated polio virus is a vaccine that protects against poliomyelitis, a viral disease that can cause paralysis or death and can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice D reason: This is an immunization that the nurse should identify as needed for this client because herpes zoster is a viral disease that causes shingles, a painful rash with blisters that can affect any part of the body and can be prevented by vaccination in older adults. The nurse should recommend that the client receive two doses of herpes zoster vaccine at least 2 months apart.
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