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:
The age of the client might influence the care plan and potential complications, but it's not the primary factor for evaluating cost effectiveness. Cost efficiency is more directly related to the resources utilized during the client's stay.
Choice B rationale:
The availability of community support groups contributes to the client's psychosocial well-being and support network, but it doesn't directly assist in evaluating the cost effectiveness of care. This factor focuses more on the quality of life after discharge.
Choice C rationale:
This is the correct choice. The length of the client's stay directly impacts the cost of care. A longer stay involves more resources, medications, and services, leading to increased costs. Evaluating and optimizing the length of stay is a critical aspect of cost-effective care.
Choice D rationale:
The type of insurance the client carries affects their financial responsibility for the care received, but it's not the main consideration for evaluating cost effectiveness. It primarily influences the patient's out-of-pocket expenses rather than the overall cost of care.
Correct Answer is A
Explanation
The correct answer is choice A: "I delegate tasks to personnel based on their job descriptions."
Choice A rationale:
The response "I delegate tasks to personnel based on their job descriptions" is appropriate in this situation. Charge nurses are responsible for delegating tasks based on the scope of practice and job descriptions of the staff members. This response emphasizes the importance of adhering to established roles and responsibilities within the healthcare team.
Choice B rationale:
The statement "Everyone working here has to care for clients who are incontinent" may be true, but it does not address the specific concern raised by the assistive personnel (AP). It's important to provide a more focused response that addresses the AP's feelings and concerns.
Choice C rationale:
While discussing workflow organization to reduce the number of incontinent clients (Choice C) might be a potential solution, it doesn't directly address the AP's statement about fairness. The charge nurse's response should prioritize explaining the delegation process and addressing the AP's concerns about fairness.
Choice D rationale:
The response "Why do you not want to care for clients who are incontinent?" could be perceived as confrontational and defensive. It's essential to maintain a respectful and supportive tone when addressing staff concerns. This response does not effectively address the situation or provide a solution.
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