Nokea
The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply.
- A. Place pillows or a wedge pillow between the client's legs to keep them abducted.
- B. Have the client flex the unaffected hip and use the trapeze to help move up in bed.
- C. Raise the head of the bed to no more than 90 degrees when the bed is placed contour.
- D. Place a pillow between the client's knees when initially assisting the client out of bed.
- E. Applies antiembolism stockings that should not be removed for 24 hours postoperatively.
Correct Answer: A,B,D
Rationale: A. A pillow should be used to maintain abduction to prevent dislocation. B. Using the trapeze and flexing the unaffected legs while keeping the affected leg straight help prevent flexion with position changes. The client's hip should not be flexed more than 90 degrees. D. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation.
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The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply.
- A. Numbness and mottled cyanosis.
- B. Paresthesia and paralysis.
- C. Proximal pulses and point tenderness.
- D. Coldness of the extremity and crepitus.
- E. Palpable radial pulse and functional movement.
Correct Answer: A,B,D
Rationale: Numbness, cyanosis, paresthesia, paralysis, coldness, and crepitus indicate compartment syndrome or neurovascular compromise, serious fracture complications. Pulses and tenderness are expected.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.
The Muslim client practicing Islam is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse is respectful of the client's faith beliefs?
- A. I'm going to uncover your hip and leg now to check the incision and your pulses.'
- B. A dietitian helps to plan your meals so that meat and dairy products are not together.'
- C. I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends.'
- D. I should let the care team know not to bring food or beverages from sunrise to sunset.'
Correct Answer: D
Rationale: D. During the month of Ramadan, those of the Islamic faith do not eat or drink from sunrise to sunset.
It is necessary to pull the client, who is in Russell's traction, up in bed. Which action should the nurse take?
- A. Leave the weights in place.
- B. Remove the weights completely.
- C. Reduce the weight of the traction by one half.
- D. Have one nurse lift the weights while the others pull the client.
Correct Answer: A
Rationale: Leaving weights in place maintains continuous traction, preventing misalignment during repositioning.
Which instruction should the nurse reinforce to ensure that the exercises are done correctly?
- A. Move your toes toward and away from your head.
- B. Contract and relax your thigh muscles.
- C. The client's effect on the use of the head.
- D. Bend your knee and pull your lower leg upward.
Correct Answer: B
Rationale: Isometric quadriceps-setting exercises involve contracting and relaxing the thigh muscles without joint movement, strengthening the muscle while minimizing stress on the surgical site. The other options describe different movements.