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 reason: This is not an appropriate action because using safety pins to secure the pad in place can puncture or damage the pad and cause leakage or malfunction. The nurse should use Velcro straps or tape to secure the pad in place.
Choice B reason: This is an appropriate action because covering the pad prior to use can prevent direct contact between the pad and the skin and reduce the risk of burns or irritation. The nurse should use a clean towel or sheet to cover the pad.
Choice C reason: This is not an appropriate action because applying the pad for 45 minutes at a time can cause tissue damage or necrosis due to prolonged exposure to heat. The nurse should apply the pad for no more than 20 minutes at a time and check the skin condition frequently.
Choice D reason: This is not an appropriate action because filling the pad with sterile water can increase the cost and waste of resources without any benefit. The nurse should fill the pad with tap water as instructed by the manufacturer.
Correct Answer is C
Explanation
Choice A reason: This is not an essential safety measure because the nurse should wear a mask only when they are within 3 feet of the client who has pneumonia and is on droplet precautions, according to the Centers for Disease Control and Prevention (CDC) guidelines. The nurse should wear a mask when entering the client's room, but they can remove it when leaving the room or transporting the client.
Choice B reason: This is not an essential safety measure because the nurse should wear a gown only when they anticipate contact with the client's blood, body fluids, secretions, or excretions, according to the CDC guidelines. The nurse should wear a gown when entering the client's room, but they can remove it when leaving the room or transporting the client.
Choice C reason: This is an essential safety measure because the client should wear a mask during transport to prevent the spread of respiratory droplets that may contain infectious agents, such as bacteria or viruses, that cause pneumonia, according to the CDC guidelines. The nurse should instruct the client to wear a mask before leaving the room and ensure that it covers their nose and mouth.
Choice D reason: This is not an essential safety measure because the client should wear a gown only if they have drainage or soiling of their clothing that may contaminate the environment, according to the CDC guidelines. The nurse should assess the client's condition and provide a clean gown if needed before leaving the room.
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