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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:Furnaces should typically be inspected annually to ensure they are functioning safely and efficiently, reducing the risk of carbon monoxide poisoning or other hazards.
Choice B reason: This is not a correct instruction because placing area rugs on wooden floors can cause tripping, slipping, or falling that can result in injuries or fractures in older adults. The nurse should instruct the client to remove any loose rugs, mats, or carpets from their home or secure them with double-sided tape or non-slip backing.
Choice C reason:Placing white tape on the edges of stairs improves visibility and helps prevent falls, particularly for older adults who may have impaired vision or difficulty judging depth.
Choice D reason: This is not a correct instruction because running wires and cords under carpeting can cause fire hazards, electrical shocks, or tripping that can endanger the client's health and safety. The nurse should instruct the client to keep wires and cords away from walkways, furniture, or heat sources and use cord covers or organizers to prevent tangling.
Correct Answer is C
Explanation
Choice A reason: Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.
Choice B reason: This is not an appropriate action because administering the feeding solution at a cold temperature can cause abdominal cramps, nausea, or vomiting. The nurse should warm the feeding solution to room temperature before administering it.
Choice C reason: Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.
Choice D reason: This is not an appropriate action because rotating the jejunostomy tube once per day can cause irritation or displacement of the tube. The nurse should secure the tube in place and check its position before each feeding.
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