A nurse is caring for a client who had total hip arthroplasty 2 days ago. Which of the following actions should the nurse take
Instruct the client to bend at the waist to put on slippers
Keep the client's heels elevated while in bed
Massage the clients affected leg three times daily
Maintain slight adduction of the client's affected hip
None
None
The Correct Answer is B
A. Instructing the client to bend at the waist is incorrect because hip flexion beyond 90 degrees is contraindicated after total hip arthroplasty due to risk of dislocation.
B. Keeping the client’s heels elevated while in bed is correct. This helps prevent pressure ulcers, which are a common postoperative complication due to decreased mobility.
C. Massaging the affected leg is contraindicated because it can dislodge a thrombus and lead to complications such as a pulmonary embolism.
D. Maintaining adduction of the affected hip is incorrect because it increases the risk of hip dislocation. The hip should be kept in abduction using a pillow or abduction device.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Serum calcium level: Cushing’s disease does not typically cause elevated calcium levels. Calcium levels are usually normal unless there is an underlying bone disorder or concurrent condition affecting calcium metabolism.
B. Lymphocyte count: Cortisol excess in Cushing’s disease suppresses the immune system, leading to lymphopenia rather than an increased lymphocyte count. A decreased lymphocyte count is more consistent with the disease process.
C. Serum glucose level: Elevated cortisol levels increase gluconeogenesis and decrease glucose uptake by cells, resulting in hyperglycemia. Clients with Cushing’s disease often exhibit elevated blood glucose as a direct effect of excess cortisol.
D. Serum potassium level: Cortisol has mineralocorticoid activity, promoting potassium excretion by the kidneys. As a result, clients with Cushing’s disease commonly have hypokalemia rather than increased serum potassium levels.
Correct Answer is A
Explanation
Rationale:
A. "Plan to take this medication with food.": Taking phenytoin with food can help reduce gastrointestinal irritation, such as nausea and upset stomach, which is a common side effect. Consistent administration with meals improves tolerability while maintaining therapeutic drug levels.
B. "Limit foods that contain folic acid while taking this medication.": Phenytoin can actually decrease folic acid absorption, and limiting folic acid intake could worsen potential deficiencies. Instead, monitoring and possibly supplementing folic acid may be recommended. Advising restriction could be harmful.
C. "Limit foods that contain vitamin D while taking this medication.": Phenytoin can reduce vitamin D metabolism, which may increase the risk of bone loss and fractures. Limiting vitamin D intake is not advised; rather, ensuring adequate vitamin D and calcium intake is important for older adults to maintain bone health.
D. "Plan to take this medication with antacids.": Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Taking phenytoin with antacids is contraindicated, and spacing the timing between antacids and phenytoin is necessary to maintain therapeutic levels.
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