A nurse is reinforcing teaching with a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
Perform range of motion by adducting the hip.
Sit in a straight-backed chair.
Cleanse the surgical incision with hydrogen peroxide.
Apply moist heat to the incision while in bed.
The Correct Answer is B
Choice A reason: Performing range of motion by adducting the hip is an incorrect instruction for a client who had a total hip arthroplasty. Adduction is moving the leg toward the midline of the body, which can cause dislocation of the prosthesis. The nurse should instruct the client to perform range of motion by abducting (moving away from midline), flexing (bending), and extending (straightening) the hip as prescribed by physical therapy.
Choice B reason: Sitting in a straight-backed chair is a correct instruction for a client who had a total hip arthroplasty. This position helps to maintain proper alignment and stability of the hip joint and prevents excessive flexion or rotation that can cause dislocation. The nurse should also instruct the client to avoid crossing legs, bending forward more than 90 degrees, or twisting at the waist.
Choice C reason: Cleansing the surgical incision with hydrogen peroxide is an incorrect instruction for a client who had a total hip arthroplasty. Hydrogen peroxide is a harsh agent that can damage healthy tissue and delay healing. The nurse should instruct the client to cleanse the incision with mild soap and water or as directed by the provider and keep it dry and covered with sterile dressing.
Choice D reason: Applying moist heat to the incision while in bed is an incorrect instruction for a client who had a total hip arthroplasty. Moist heat can increase swelling, inflammation, and infection risk at the incision site. The nurse should instruct the client to apply ice packs or cold compresses to the incision as needed to reduce pain and swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate area to check for pallor because the antecubital space, or the inner elbow, is not a reliable indicator of skin color changes due to variations in pigmentation and blood flow.
Choice B reason: This is not an appropriate area to check for pallor because the pinna of the ear, or the outer ear, is not a reliable indicator of skin color changes due to variations in pigmentation and blood flow.
Choice C reason: This is not an appropriate area to check for pallor because the abdomen is not a reliable indicator of skin color changes due to variations in pigmentation and fat distribution.
Choice D reason: This is an appropriate area to check for pallor because the conjunctiva, or the inner lining of the eyelid, is a reliable indicator of skin color changes due to its consistent pink color in healthy individuals regardless of race or ethnicity. Pallor of the conjunctiva can indicate anemia or shock.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action because performing hand hygiene with hands at elbow level can contaminate or recontaminate hands by allowing water or soap to drip from elbows to hands or wrists. The nurse should perform hand hygiene with hands lower than elbows and avoid touching faucets or sinks with hands or forearms.
Choice B reason: This is an appropriate action because cleaning a blood spill with chlorine bleach can disinfect and decontaminate surfaces that have been exposed to bloodborne pathogens, such as hepatitis B virus or human immunodeficiency virus. The nurse should wear gloves and use a 1:10 dilution of bleach and water to clean the spill.
Choice C reason: This is not an appropriate action because instructing a female client to wipe her perineal area from back to front can increase the risk of urinary tract infection or vaginal infection by introducing bacteria from the anus to the urethra or vagina. The nurse should instruct the client to wipe her perineal area from front to back and use a clean tissue for each wipe.
Choice D reason: This is not an appropriate action because rolling soiled linen with clean side in before placing it in laundry bag can spread microorganisms or body fluids to hands, clothing, or environment. The nurse should fold or roll soiled linen with dirty side in and avoid shaking or tossing it.
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