A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?
Teach the client which positions to avoid during PT.
Identify the client's pain level and medicate if needed.
Perform the client's morning care.
Encourage the client to use full weight bearing.
The Correct Answer is B
B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.
A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.
C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.
D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.
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Related Questions
Correct Answer is C
Explanation
C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.
A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.
B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.
D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.
Correct Answer is D
Explanation
D. Difficulty or inability to abduct (raise out to the side) the arm at the shoulder is a classic finding in rotator cuff injuries, particularly in cases of significant tears or severe inflammation. This limitation in shoulder movement can be due to pain, weakness, or mechanical impingement caused by the injured rotator cuff.
A. The drop arm test is a physical examination maneuver used to assess for rotator cuff tears. In a negative drop arm test, the patient is able to slowly lower their arm from an abducted position (out to the side) to their side without significant pain or weakness. A negative test suggests that there may not be a complete tear of the rotator cuff.
B. Alteration in the contour of the shoulder joint could indicate various shoulder pathologies, including rotator cuff injuries. However, it is a nonspecific finding and can occur with other shoulder conditions as well.
C. Tinel's sign is a test used to assess for nerve compression or irritation. While it can be positive in conditions such as carpal tunnel syndrome, it is not typically associated with rotator cuff injuries.
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