A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?

Raising the bed linens off the client's feet to prevent plantar flexion.

Keeping the client's heels off the bed to prevent pressure ulcers.

Positioning the client off the operative site while in bed.

Preventing dislocation of the hip during position changes or movement.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect purpose, because raising the bed linens off the client's feet to prevent plantar flexion is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Raising the bed linens off the client's feet can be achieved by using a foot cradle or a bed frame.

Choice B reason: This is an incorrect purpose, because keeping the client's heels off the bed to prevent pressure ulcers is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Keeping the client's heels off the bed can be achieved by using a heel protector or a pillow under the lower legs.

Choice C reason: This is an incorrect purpose, because positioning the client off the operative site while in bed is not related to the use of an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and aligned. Positioning the client off the operative site can be achieved by using a trochanter roll or a pillow under the hip.

Choice D reason: This is the correct purpose, because preventing dislocation of the hip during position changes or movement is the main reason for using an abduction pillow. An abduction pillow is a wedge-shaped pillow that is placed between the client's legs to keep them apart and

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

A. Obtain the prescribed irrigation solution. B. Don personal protective equipment. C. Check the client's pain level. D. Place a waterproof pad under the client's extremity.

Correct Answer is C

Explanation

Choice A reason: This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.

Choice B reason: This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.

Choice C reason: This is the correct action, because checking the client's pain level is the first step in the wound care process. The nurse should assess the client's pain level using a valid and reliable pain scale, and administer analgesia as prescribed before irrigating the wound.

Choice D reason: This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.

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A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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