A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

"I will use a pillow between my legs when I sleep.”

"I will avoid crossing my legs or bending forward.”

"I will report any signs of infection or bleeding to my doctor.”

"I will resume my normal activities as soon as I feel better.”

"I will take my anticoagulant medication as prescribed."

Answer and Explanation

Correct Answer : D,E

Choice A reason:

This is a correct statement by the client. Using a pillow between the legs when sleeping helps to maintain the hip in abduction and prevent dislocation of the prosthesis.

Choice B reason:

This is also a correct statement by the client. Avoiding crossing the legs or bending forward prevents excessive flexion of the hip and reduces the risk of dislocation.

Choice C reason:

This is another correct statement by the client. Reporting any signs of infection or bleeding to the doctor is important to prevent complications such as wound infection, hematoma, or sepsis.

Choice D reason:

This is an incorrect statement by the client that indicates a need for further teaching. Resuming normal activities as soon as the client feels better is not advisable, as it may cause excessive stress on the joint and lead to loosening or fracture of the prosthesis. The client should follow a gradual rehabilitation program and avoid activities that involve high impact, twisting, or lifting.

Choice E reason:

This is also an incorrect statement by the client that indicates a need for further teaching. Taking anticoagulant medication as prescribed is not enough to prevent thromboembolic events after a total hip replacement. The client should also wear compression stockings, use intermittent pneumatic compression devices, and perform ankle and foot exercises as instructed. The client should also monitor for signs of bleeding or bruising and report any abnormal findings to the doctor.

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Correct Answer is C

Explanation

Choice A reason:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B reason:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C reason:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D reason:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

A. "I will give you some medication to help with your pain.” B. "Can you describe how your pain affects your daily activities?” C. "How long have you had this pain and what makes it better or worse?” D. "That sounds very painful, I'm sorry you are going through this."

Correct Answer is B

Explanation

Choice A reason:

This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.

Choice B reason:

This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.

Choice C reason:

This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.

Choice D reason:

This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.

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A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assessing a patient's pain level after surgery. The patient rates their pain as 8 out of 10 and says it feels like a sharp stabbing pain in the surgical site. What should the nurse say to the patient?

Correct Answer is B

Explanation

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A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)