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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer is: Wear an N95 respirator mask when in the client’s room.
Explanation: Pulmonary tuberculosis (TB) is a contagious disease caused by bacteria that can spread through the air. The most common way of transmission is through respiratory droplets that are expelled when a person with active TB coughs, sneezes, or speaks1. Therefore, the charge nurse should expect the newly licensed nurse to take precautions to protect themselves and the client from exposure to TB. One of these precautions is to wear an N95 respirator mask when in the client’s room2. An N95 respirator mask is a type of personal protective equipment (PPE) that filters out at least 95% of airborne particles, including bacteria and viruses3. It can prevent the nurse from inhaling or spreading TB to others.
The other options are incorrect because:
Place the client on droplet precautions: Droplet precautions are not enough to prevent transmission of TB, as they only protect against respiratory droplets that are less than 5 micrometers in diameter1. However, TB bacteria can be found in larger droplets that can travel farther and infect people who are not in direct contact with the source1.
Place the client in a room with positive-pressure airflow: Positive-pressure airflow is not effective against TB, as it does not reduce the concentration of airborne particles or prevent them from escaping through cracks and gaps in doors and windows. Moreover, positive-pressure airflow can create negative pressure in other areas of the facility, which can increase the risk of cross-contamination.
Wear a surgical mask when taking the client out of the room: A surgical mask is not sufficient to protect against TB, as it only filters out particles that are larger than 5 micrometers in diameter3. It also does not fit properly on the face and may allow some particles to pass through3.
Correct Answer is C
Explanation
Choice A rationale:
Writing a memorandum emphasizing the importance of attending staff meetings might help remind the staff about the significance of these meetings. However, it does not address the root causes of the poor attendance issue. Exploring the reasons behind the lack of attendance should come before issuing reminders.
Choice B rationale:
Appointing a task force to promote attendance at the meetings is a proactive step. However, it might be premature without understanding the reasons for the poor attendance. The task force's efforts could be more effective if informed by a thorough analysis of the underlying issues.
Choice C rationale:
Exploring the reasons that staff are not attending the meetings is the crucial first step. Understanding the factors contributing to the poor attendance allows the charge nurse to tailor interventions appropriately. Reasons could include scheduling conflicts, lack of engagement, or dissatisfaction with meeting content.
Choice D rationale:
Reducing the number of meetings staff are required to attend might address the attendance issue, but it doesn't address the root causes. It's important to identify the reasons behind poor attendance before making decisions about changing meeting frequency.
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