Which of the following actions should the nurse take immediately to prevent complications?

Encourage the patient to cross their legs while dressing to reduce strain on the hip joint.

Allow the patient to continue dressing independently to promote mobility.

Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees.

Instruct the patient to bend forward slowly and use both hands to pull up the socks.

Answer and Explanation

The Correct Answer is C

A. Encourage the patient to cross their legs while dressing to reduce strain on the hip joint: Crossing the legs after hip surgery increases the risk of hip dislocation by placing excessive stress on the hip joint. This is incorrect and unsafe.

B. Allow the patient to continue dressing independently to promote mobility: While encouraging independence is important, allowing the patient to continue this action violates hip precautions (no bending past 90°). The patient must be stopped to prevent complications.

C. Stop the patient immediately and reinforce hip precautions, advising against hip flexion greater than 90 degrees. After THA, the hip should not be flexed more than 90° as this can cause hip dislocation. The nurse should stop the patient immediately and educate them on proper dressing techniques.

D. Instruct the patient to bend forward slowly and use both hands to pull up the socks. Bending forward, even slowly, violates hip precautions and increases the risk of dislocation. The patient should use adaptive devices, such as a sock aid, instead.

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Correct Answer is D

Explanation

A. Medicate the client for pain: Pain management is essential after surgery; however, it is not the most critical action. Unrelieved pain could indicate a complication, such as compartment syndrome, which requires further assessment.

B. Direct the client to perform exercises of the ankle and toes: Performing ankle and toe exercises helps prevent complications such as venous thromboembolism (VTE) and promotes circulation, but it is not the priority over assessing for complications.

C. Instruct the client on the use of crutches: Teaching the client how to use crutches is important for mobility, but this is not the most immediate postoperative concern.

D. Perform neurovascular checks of the extremities: This is the most important intervention because neurovascular compromise (e.g., compartment syndrome) can occur after orthopedic surgery. Checking circulation, movement, and sensation (CMS) is critical for early detection of complications.

A. Fat embolism syndrome B. Deep vein thrombosis (DVT) C. Compartment syndrome D. Cast syndrome (Superior Mesenteric Artery Syndrome - SMAS)

Correct Answer is D

Explanation

A. Fat embolism syndrome: Fat embolism syndrome (FES) typically presents with respiratory symptoms, such as dyspnea, petechiae, and confusion. Gastrointestinal symptoms like nausea and bloating are not characteristic of FES.

B. Deep vein thrombosis (DVT): DVT primarily presents with unilateral leg swelling, pain, and warmth, rather than gastrointestinal symptoms. While immobilization increases the risk of DVT, the patient’s symptoms do not align with this condition.

C. Compartment syndrome: Compartment syndrome involves severe pain, pallor, paresthesia, pulselessness, and paralysis in an affected limb. Gastrointestinal symptoms are not associated with compartment syndrome.

D. Cast syndrome (Superior Mesenteric Artery Syndrome - SMAS): SMAS occurs when the full-body cast compresses the superior mesenteric artery, leading to nausea, bloating, abdominal pain, and weight loss due to gastric obstruction. This condition is common in patients immobilized for prolonged periods.

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Which of the following actions should the nurse take immediately to prevent complications?

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Explanation

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