Which of the following actions should the nurse take immediately to prevent complications?

Encourage the patient to cross their legs while dressing to reduce strain on the hip joint.

Allow the patient to continue dressing independently to promote mobility.

Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees.

Instruct the patient to bend forward slowly and use both hands to pull up the socks.

Answer and Explanation

The Correct Answer is C

A. Encourage the patient to cross their legs while dressing to reduce strain on the hip joint: Crossing the legs after hip surgery increases the risk of hip dislocation by placing excessive stress on the hip joint. This is incorrect and unsafe.

B. Allow the patient to continue dressing independently to promote mobility: While encouraging independence is important, allowing the patient to continue this action violates hip precautions (no bending past 90°). The patient must be stopped to prevent complications.

C. Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees. After THA, the hip should not be flexed more than 90° as this can cause hip dislocation. The nurse should stop the patient immediately and educate them on proper dressing techniques.

D. Instruct the patient to bend forward slowly and use both hands to pull up the socks. Bending forward, even slowly, violates hip precautions and increases the risk of dislocation. The patient should use adaptive devices, such as a sock aid, instead.

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Correct Answer is B

Explanation

A. "Handwashing is not necessary since impetigo is not contagious." Impetigo is highly contagious, and proper hand hygiene is essential to prevent its spread to others.

B. “I should apply Mupirocin (Bactroban) to the affected areas as prescribed." Mupirocin (Bactroban) is the standard topical antibiotic treatment for impetigo and should be applied as prescribed to reduce bacterial colonization and promote healing.

C. “I don't need to cover the lesions; they should be left open to the air." Covering the lesions can help prevent the spread of infection by minimizing contact with contaminated surfaces.

D. “I will let my child scratch the lesions to help them dry out faster." Scratching can worsen the infection, spread bacteria to other parts of the body, and lead to secondary infections.

A. Moderate level of pain B. Dependent edema distal to the cast C. Itching of the distal foot D. Inability to flex the toes of the casted foot

Correct Answer is D

Explanation

A. Moderate level of pain: Pain is expected after a fracture and casting. However, if pain is severe and unrelieved by medication, it may indicate compartment syndrome, which is an emergency. Moderate pain alone does not require immediate provider notification.

B. Dependent edema distal to the cast: Some swelling is expected due to reduced mobility and gravity-dependent positioning. Elevating the leg can help reduce swelling, but it does not require immediate provider notification.

C. Itching of the distal foot: Itching is a common, non-emergency side effect of casting. Clients should be advised not to insert objects inside the cast to relieve itching.

D. Inability to flex the toes of the casted foot: Inability to flex the toes suggests potential neurovascular compromise or compartment syndrome, a medical emergency requiring immediate intervention to prevent permanent nerve or muscle damage. The provider must be notified immediately.

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Which of the following actions should the nurse take immediately to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to the parent of a child diagnosed with impetigo. Which of the following statements by the parent indicates a correct understanding of the treatment plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider?

Correct Answer is D

Explanation

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