A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following Instructions should the nurse include?

"You should avoid putting a pillow between your legs when in bed."

"You should avoid exercising for the next 6 weeks."

"You should avoid lying on your right side."

"You should avoid crossing your legs for 3 months."

Answer and Explanation

The Correct Answer is C

A.   Placing a pillow between the legs can actually provide support and comfort when lying on the back or non-operative side.
B.   Gentle exercises are typically encouraged after hip arthroplasty to promote circulation and prevent complications.
C.   Correct. Avoiding lying on the operative side helps prevent dislocation of the new hip joint.
D.   Avoiding crossing the legs helps prevent hip joint stress, but avoiding lying on the operative side is more crucial.

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Correct Answer is D

Explanation

A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.

A. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. B. A client received an 0900 daily medication at 1000. C. A client who has an infection refused the evening meal. D. A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. E. A client fell when ambulating to the bathroom alone.

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

Explanation

The nurse should write an incident report for the following events:
1. An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2. A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3. A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

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A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following Instructions should the nurse include?

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