The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?
An abduction pillow is placed between the client's legs when positioned.
The client is told to keep both legs straight and together while turning.
A turning sheet is used under the client for turning and repositioning.
The UAPs keep their backs straight and knees bent when moving the client.
The Correct Answer is B
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned correctly and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet is used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.
Choice A rationale:
Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the
use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.
Choice B rationale:
Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.
Choice C rationale:
Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.
Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.
Choice D rationale:
Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.
Neurovascular assessments are more critical for the early detection of complications.
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
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