A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

Assess the client's incision every 8 hours for the first 48 hours.

Inform the assistive personnel of the client's weight-bearing status.

Instruct the client to cross their legs at the ankles when sitting in a chair.

Teach the client's partner to assist the client to flex the hip at least 120° each hour.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.

Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.

Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.

Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.

Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.

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Correct Answer is C

Explanation

Choice A rationale:

Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.

Choice B rationale:

Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.

Choice C rationale:

Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.

Choice D rationale:

Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.

A. "I delegate tasks to personnel based on their job descriptions.” B. "Everyone working here has to care for clients who are incontinent.” C. "Let's talk about organizing the workflow so you care for fewer of these clients.” D. "Why do you not want to care for clients who are incontinent?”

Correct Answer is A

Explanation

The correct answer is choice A: "I delegate tasks to personnel based on their job descriptions."

Choice A rationale:

The response "I delegate tasks to personnel based on their job descriptions" is appropriate in this situation. Charge nurses are responsible for delegating tasks based on the scope of practice and job descriptions of the staff members. This response emphasizes the importance of adhering to established roles and responsibilities within the healthcare team.

Choice B rationale:

The statement "Everyone working here has to care for clients who are incontinent" may be true, but it does not address the specific concern raised by the assistive personnel (AP). It's important to provide a more focused response that addresses the AP's feelings and concerns.

Choice C rationale:

While discussing workflow organization to reduce the number of incontinent clients (Choice C) might be a potential solution, it doesn't directly address the AP's statement about fairness. The charge nurse's response should prioritize explaining the delegation process and addressing the AP's concerns about fairness.

Choice D rationale:

The response "Why do you not want to care for clients who are incontinent?" could be perceived as confrontational and defensive. It's essential to maintain a respectful and supportive tone when addressing staff concerns. This response does not effectively address the situation or provide a solution.

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A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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