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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

A. Compare data from clients' records regarding skin integrity with established criteria. B. Measure staff attendance at an educational program on managing pressure injuries. C. Interview clients regarding their satisfaction with their care. D. Monitor use of supplies used to prevent pressure injuries.

Correct Answer is A

Explanation

The correct answer is choice A: Compare data from clients' records regarding skin integrity with established criteria.

Choice A rationale:

Comparing data from clients' records regarding skin integrity with established criteria (Choice A) is essential for evaluating the effectiveness of the plan to decrease pressure injuries. This action helps identify trends, improvements, or areas that still need attention.

Choice B rationale:

Measuring staff attendance at an educational program on managing pressure injuries (Choice B) assesses staff participation but does not directly evaluate the plan's impact on pressure injury rates. Attendance does not necessarily translate to improved implementation.

Choice C rationale:

Interviewing clients regarding their satisfaction with their care (Choice C) focuses on client satisfaction rather than evaluating the effectiveness of the plan in reducing pressure injuries. While satisfaction is important, it does not directly measure the plan's success.

Choice D rationale:

Monitoring use of supplies used to prevent pressure injuries (Choice D) provides information on resource utilization but does not provide comprehensive data on the plan's effectiveness. It does not account for the effectiveness of staff adherence to pressure injury prevention protocols.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

Correct Answer is B

Explanation

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take?

A hospice nurse is planning care for a client who does not have advance directives. Which of the following interventions should the nurse include in the plan of care?

A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

A charge nurse is observing a newly licensed nurse who is caring for a client who has pulmonary tuberculosis. The charge nurse should expect the newly licensed nurse to take which of the following actions?

A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team?

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?