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 asking the client's health care surrogate for permission to withhold nourishment can violate the client's autonomy and dignity. The nurse should respect the client's wishes and preferences regarding end-of-life care and document them clearly.
Choice B reason: This is an appropriate action because providing regular oral care for the client with a moist swab can prevent dryness, cracking, or infection of the mouth and lips and enhance comfort and quality of life. The nurse should also apply lip balm or petroleum jelly as needed.
Choice C reason: This is not an appropriate action because requesting a prescription for IV fluids can cause fluid overload, edema, or dyspnea in the dying client and prolong their suffering. The nurse should follow the provider's orders regarding hydration and nutrition and monitor the client's fluid balance status.
Choice D reason: This is not an appropriate action because explaining the importance of oral hydration to the client can be perceived as coercive or insensitive and cause distress or guilt in the dying client. The nurse should acknowledge the client's decision and provide emotional support and education.
Correct Answer is D
Explanation
Choice A reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Metformin is an oral antidiabetic drug that lowers blood glucose levels by decreasing hepatic glucose production and increasing insulin sensitivity.
Choice B reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Atorvastatin is a statin drug that lowers blood cholesterol levels by inhibiting an enzyme involved in cholesterol synthesis.
Choice C reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Omeprazole is a proton pump inhibitor drug that lowers stomach acid levels by blocking an enzyme involved in acid secretion.
Choice D reason: This medication needs to be avoided within 24 hours of using nitroglycerin because it can interact with nitroglycerin and cause severe hypotension and syncope. Sildenafil is a phosphodiesterase inhibitor drug that treats erectile dysfunction by increasing blood flow to the penis by relaxing smooth muscle cells.
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