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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Providing information about other birth control methods is appropriate after the nurse explores the client's uncertainty, as it ensures the client's decision-making process is supported by understanding all available options.

Choice B rationale: While involving a partner can be helpful, the nurse’s primary responsibility is to the client’s autonomy; asking this first may shift the focus away from the client’s personal concerns.

Choice C rationale: Emphasizing only the benefits is non-therapeutic and biased. The nurse must remain neutral and allow the client to weigh both the benefits and risks of a permanent procedure.

Choice D rationale: Active listening and exploring the client's feelings are the first steps in the nursing process to address uncertainty. This allows the client to clarify their values and reach an informed decision.

A. "Change-of-shift report can be given at the client's bedside.” B. "I can provide client information over the phone if the caller identifies themselves as family.” C. "A client cannot see their medical record because it is considered to be property of the facility.” D. "Access to client information is limited to direct care providers.”

Correct Answer is D

Explanation

Choice A rationale:

Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.

Choice B rationale:

Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.

Choice C rationale:

Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.

Choice D rationale:

Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.

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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?

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