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 C

Explanation

Choice A rationale:

The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.

Choice B rationale:

The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.

Choice C rationale:

The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.

Choice D rationale:

The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.

A. "It sounds like nonpharmacological interventions would be best for this client.” B. "Let's withhold the oxycodone until we can consult with the provider.” C. "Contact mental health services to arrange for a consultation.” D. "Clients are the experts on their own pain.”

Correct Answer is D

Explanation

Answer is: d. "Clients are the experts on their own pain."

Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.

Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.

Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.

Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

Correct Answer is C

Explanation

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

Correct Answer is D

Explanation

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