A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?
Transferring from sitting to standing position
Straining during a bowel movement
Bending down to put socks on
Turning in bed with an abductor pillow in place
Crossing the legs or ankles
The Correct Answer is C
Choice A reason: Transferring from sitting to standing position is not a high-risk activity for hip dislocation, as long as the client follows the proper precautions, such as keeping the operated leg slightly forward, using a chair with armrests, and avoiding twisting or pivoting the hip.
Choice B reason: Straining during a bowel movement is not a direct risk factor for hip dislocation, but it may cause constipation, which is a common problem after surgery. The nurse should educate the client on the importance of adequate hydration, fiber intake, and stool softeners to prevent constipation and reduce the need for straining.
Choice C reason: Bending down to put socks on is a risky activity for hip dislocation, as it violates the hip precautions of avoiding flexing the hip more than 90 degrees, adducting the hip, or internally rotating the hip. The nurse should instruct the client to use assistive devices, such as a sock aid or a long-handled reacher, to put on socks or shoes without bending the hip.
Choice D reason: Turning in bed with an abductor pillow in place is a safe activity for hip dislocation, as the abductor pillow helps to maintain the alignment and stability of the hip joint. The nurse should teach the client to use the abductor pillow while in bed for the first few weeks after surgery, and to turn from side to side with the assistance of a caregiver.
Choice E reason: Crossing the legs or ankles is a dangerous activity for hip dislocation, as it causes the hip to move out of its normal position. The nurse should remind the client to keep the legs apart at all times, and to use a pillow or a wedge between the legs when lying on the side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Choice A reason: Pain management is not a key information to include in the education plan for a client with psoriasis, as psoriasis is not usually a painful condition. It may cause itching, burning, or soreness, but these are not severe enough to require pain medication.
Choice B reason: Watching skin every hour to prevent infection is not a realistic or necessary information to include in the education plan for a client with psoriasis, as psoriasis is not an infectious condition. It is an autoimmune disorder that causes the skin cells to grow faster than normal, resulting in thick, scaly, red patches on the skin.
Choice C reason: Avoiding public places until symptoms subside is not a helpful or appropriate information to include in the education plan for a client with psoriasis, as psoriasis is not a contagious condition. It does not pose a risk to others, and isolating oneself may worsen the client's mental and emotional health.
Choice D reason: Antifungal ointment will not be part of the long-term management for a client with psoriasis, as psoriasis is not a fungal infection. It is an immune-mediated condition that requires different types of treatments, such as topical steroids, vitamin D analogues, phototherapy, or biologics.
Choice E reason: Moisturizing skin regularly and avoiding triggers is a correct information to include in the education plan for a client with psoriasis, as it helps to reduce the dryness, scaling, and inflammation of the skin. Triggers may vary from person to person, but some common ones are stress, infections, cold weather, alcohol, smoking, or certain medications.
Correct Answer is A
Explanation
Choice A reason: This statement is incorrect and indicates the need for further education. Failure to rescue is not the ability of the nurse to save a client's life, but the inability or failure to do so. It is defined as the death of a hospitalized client who experienced a potentially preventable complication.
Choice B reason: This statement is correct and does not indicate the need for further education. Failure to rescue includes the failure of the nurse to report changes in a client's condition to the provider, which could delay the diagnosis and treatment of the complication.
Choice C reason: This statement is correct and does not indicate the need for further education. Failure to rescue is the failure to recognize a client's condition is deteriorating, which could lead to missed opportunities for intervention and prevention of adverse outcomes.
Choice D reason: This statement is correct and does not indicate the need for further education. Failure to rescue involves the lack of managing complications, which could result in increased morbidity and mortality.
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