A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?
Assess the client's incision every 8 hours for the first 48 hours.
Inform the assistive personnel of the client's weight-bearing status.
Instruct the client to cross their legs at the ankles when sitting in a chair.
Teach the client's partner to assist the client to flex the hip at least 120° each hour.
The Correct Answer is B
The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.
Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.
Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.
Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.
Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Documenting client tasks at the end of the shift is not the most effective time-management skill. While documentation is important, it should be done in a timely manner to ensure accuracy and continuity of care. Waiting until the end of the shift might lead to missed details or inaccuracies.
Choice B rationale:
Gathering supplies as needed while completing an activity is a reasonable approach to time management. However, it is not the most effective skill listed. It's often more efficient to gather all necessary supplies before starting a task to minimize interruptions and maximize focus on the activity.
Choice C rationale:
This is the correct choice. Grouping tasks that are in the same location allows the nurse to minimize unnecessary movement and maximize efficiency. By completing tasks in close proximity, the nurse can save time and reduce the need for multiple trips back and forth.
Choice D rationale:
Skipping breaks throughout the day to complete work on time is not a recommended time-management strategy. Adequate breaks are essential for nurses to recharge, prevent burnout, and provide safe and effective care. Skipping breaks can lead to decreased performance, increased stress, and potential errors in patient care.
Correct Answer is C
Explanation
The correct answer is C.
Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.
Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.
Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.
Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.
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