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 the correct answer because lime ice popsicle is a clear liquid that can help hydrate the client and soothe the stomach. Clear liquids are recommended for the first 24 hours after gastroenteritis to prevent dehydration and nausea.
Choice B reason: This is not a good choice because vanilla pudding is a dairy product that can be hard to digest and cause diarrhea or cramps. Dairy products should be avoided until the client has no symptoms for at least 48 hours.
Choice C reason: This is not a good choice because orange juice is acidic and can irritate the stomach and cause vomiting or heartburn. Acidic foods and drinks should be avoided until the client has no symptoms for at least 48 hours.
Choice D reason: This is not a good choice because cream of broccoli soup is high in fat and fiber that can be hard to digest and cause gas or bloating. High-fat and high-fiber foods should be avoided until the client has no symptoms for at least 48 hours.
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.
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