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 B
Explanation
Choice A: Instructing the client to store the injector at room temperature is not the priority because it is not a life-saving action. Storing the injector at room temperature is important to maintain its effectiveness and prevent damage from heat or cold. However, it is not as urgent as seeking medical attention or recognizing anaphylaxis.
Choice B: Informing the client to seek medical attention following administration of the injection is the priority because it is a life-saving action. Seeking medical attention following administration of the injection is essential to prevent further complications or recurrence of anaphylaxis. Anaphylaxis is a severe allergic reaction that can cause symptoms such as difficulty breathing, swelling, rash, or shock. It can be fatal if not treated promptly and properly. Epinephrine is a medication that can reverse some of the symptoms of anaphylaxis by constricting blood vessels, relaxing airways, and increasing heart rate. However, epinephrine is not a cure for anaphylaxis and its effects may wear off after 15 to 20 minutes. Therefore, the client should seek medical attention as soon as possible after using the injector.
Choice C: Having the client perform a return demonstration of the equipment is not the priority because it is not a life-saving action. Having the client perform a return demonstration of the equipment is important to assess the client's understanding and ability to use the injector correctly. However, it is not as urgent as seeking medical attention or recognizing anaphylaxis.
Choice D: Reviewing the signs of anaphylaxis with the client is not the priority because it is not a life-saving action. Reviewing the signs of anaphylaxis with the client is important to educate the client about how to identify and respond to an allergic reaction. However, it is not as urgent as seeking medical attention or using the injector.
Correct Answer is D
Explanation
Choice A reason: This is not a priority finding to report to the provider because temperature 37.8° C (100° F) indicates a mild fever that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's temperature and administer antipyretics as prescribed.
Choice B reason: This is not a priority finding to report to the provider because loss of appetite is a common symptom of appendicitis that can result from nausea, vomiting, or pain. The nurse should encourage oral fluid intake and provide clear liquids or bland foods as tolerated.
Choice C reason: This is not a priority finding to report to the provider because WBC count 15,000/mm³ indicates leukocytosis or elevated white blood cell count that can be caused by inflammation or infection of the appendix or other organs. The nurse should monitor the client's laboratory values and administer antibiotics as prescribed.
Choice D reason: This is a priority finding to report to the provider because rigid, board-like abdomen indicates peritonitis or inflammation of the peritoneum that can be caused by rupture or perforation of the appendix or other organs. This is a medical emergency that requires immediate surgical intervention and aggressive fluid and antibiotic therapy. The nurse should assess the client's abdominal pain, distension, and guarding and notify the provider immediately.
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