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: This is not an appropriate intervention because monitoring the neurovascular status of the client's affected limb every 8 hours is not frequent enough to detect any signs of impaired circulation, sensation, or movement in the limb that may result from injury, infection, or compartment syndrome. The nurse should monitor the neurovascular status of the client's affected limb at least every 2 hours and compare it with the unaffected limb.
Choice B reason: This is not an appropriate intervention because applying 4.5 kg (10 lb) traction weight to the distal end of the fixator is not indicated for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should avoid applying any weight or force to the fixator unless prescribed by the provider.
Choice C reason: This is an appropriate intervention because administering pain medication 30 minutes prior to pin care can reduce the discomfort and anxiety that the client may experience during the procedure, which involves cleaning and inspecting the pins and wires that hold the fracture fragments in place. The nurse should administer analgesics as prescribed and use aseptic technique and sterile equipment for pin care.
Choice D reason: This is not an appropriate intervention because adjusting the clamps on the device's frame daily is not within the scope of practice of a nurse who is caring for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. The nurse should leave the clamps and screws on the device untouched and notify the provider if they become loose or damaged.
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate intervention for this client because physical therapy can help with improving joint mobility and function, but not with eating difficulties. The nurse should encourage the client to perform range-of-motion exercises and apply heat or cold therapy to the affected joints as prescribed.
Choice B reason: This is not an appropriate intervention for this client because having an assistive personnel feed the client can compromise the client's dignity and independence. The nurse should respect the client's preferences and abilities and provide assistance only when needed.
Choice C reason: This is not an appropriate intervention for this client because a pureed diet is not necessary for this client unless they have swallowing problems or dental issues. The nurse should offer the client a balanced and varied diet that meets their nutritional needs and preferences.
Choice D reason: This is the correct answer because applying foam handles to the client's eating utensils can make them easier to grip and manipulate, thus enhancing the client's self-feeding ability and comfort. The nurse should also provide other adaptive devices, such as plate guards, non-slip mats, or angled spoons, as needed.
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