A nurse is assisting a client who is 2 days postoperative following a total hip arthroplasty to walk to a chair. When the nurse offers to help the client ambulate, the client refuses to get out of bed. Which of the following actions should the nurse take?

Tell the client that if she does not get out of bed she will not receive any assistance with bathing.

Acknowledge the client's wishes, but explain the importance of ambulation post operatively.

Ask for assistance from a physical therapist to help move the client out of bed.

instruct the assistive personnel (AP) to transfer the client to a chair.

Answer and Explanation

The Correct Answer is B

A. Tell the client that if she does not get out of bed she will not receive any assistance with bathing. This approach is coercive and unethical. It does not respect the client's autonomy and could harm the nurse-client relationship.

B. Acknowledge the client's wishes, but explain the importance of ambulation postoperatively. This approach respects the client's autonomy while providing education on the importance of ambulation for recovery. It encourages the client to make an informed decision.

C. Ask for assistance from a physical therapist to help move the client out of bed. While involving a physical therapist is helpful, it should be done after the nurse explains the importance of ambulation and obtains the client's consent.

D. Instruct the assistive personnel (AP) to transfer the client to a chair. This does not address the client's refusal and autonomy. Forcing the client to transfer without consent is inappropriate.

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Correct Answer is C

Explanation

A. Apply heat during the first 24 hr. Applying heat can increase swelling and should be avoided initially. Ice is recommended to reduce swelling.

B. Place moderate weight on the affected leg when walking. The affected leg should not bear weight until the initial acute phase of the injury has passed and pain/swelling has decreased.

C. Elevate the affected ankle to the level of the heart. Correct. Elevating the ankle helps to reduce swelling and promote venous return.

D. Apply the elastic compression dressing tight enough so the toes and ankle become numb. The compression dressing should be snug but not so tight that it restricts blood flow, which can lead to numbness and further injury.

A. Ultrasound B. Arthroscopy C. Serum Alkaline Phosphatase Test D. Bone Biopsy

Correct Answer is B

Explanation

A. Ultrasound: Ultrasound can be used to visualize soft tissue injuries and fluid accumulation but is not typically the first choice for long-term joint issues.
B. Arthroscopy: Arthroscopy is a minimally invasive procedure that allows direct visualization and treatment of joint problems. It is likely to be prescribed because it can help diagnose persistent pain and swelling in the knee.
C. Serum Alkaline Phosphatase Test: This blood test is used to evaluate bone growth and liver function. It is not specific for diagnosing joint pain or swelling.
D. Bone Biopsy: A bone biopsy is used to diagnose bone infections or cancer, which are not indicated in this scenario of persistent knee pain and swelling after an injury.

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A nurse is assisting a client who is 2 days postoperative following a total hip arthroplasty to walk to a chair. When the nurse offers to help the client ambulate, the client refuses to get out of bed. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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