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 C
Explanation
Choice A reason:
Offer oral fluids every 4 hours: This is incorrect because oral fluids should be offered more frequently to maintain hydration. Dehydrated patients need consistent fluid intake to prevent further fluid deficit.
Choice B reason:
Monitor pulse pressure every 6 hours: This is incorrect because pulse pressure monitoring is not a standard intervention for dehydration. Pulse pressure is more relevant for cardiovascular assessments rather than fluid status.
Choice C reason:
Check for neck vein distention: This is correct as it helps assess fluid overload, which can occur with IV fluid replacement. Jugular vein distention is a key indicator of fluid status and potential fluid overload.
Choice D reason:
Limit oral fluids prior to bedtime: This is incorrect as limiting fluids can worsen dehydration. Dehydrated patients need adequate fluid intake throughout the day.
Correct Answer is C
Explanation
Choice A reason: This is not an appropriate action to take first because pulling the fire alarm panel can alert other staff and personnel about the fire and activate the emergency response system, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should pull the fire alarm panel after removing the client from the room.
Choice B reason: This is not an appropriate action to take first because obtaining a fire extinguisher can help extinguish or contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should obtain a fire extinguisher after removing the client from the room.
Choice C reason: This is an appropriate action to take first because removing the client from the room can protect them from smoke inhalation, burns, or injuries and ensure their safety and well-being. The nurse should remove the client from the room as quickly and safely as possible and follow the RACE protocol (Rescue, Alarm, Contain, Extinguish).
Choice D reason: This is not an appropriate action to take first because closing the door to the client's room can help contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should close the door to the client's room after removing them from the room.
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