Examkin

Question

Difficulty: MediumReduction of Risk Potential

The charge nurse is rounding on a medical-surgical unit. Which observation of client care requires the charge nurse to intervene immediately to reduce the risk of a severe physiological complication?

  1. A client who had a right total hip arthroplasty (posterior approach) earlier in the day and is currently resting in bed with the right leg internally rotated.Answer
  2. B
    A client with peripheral arterial disease (PAD) of the lower extremities who is sitting in a chair with both legs positioned dependently toward the floor.
  3. C
    A client with chronic hypercapnia due to severe emphysema who is receiving oxygen at 2 L/min2\text{ L/min} via nasal cannula and has an oxygen saturation of 89%89\%.
  4. D
    A nurse who auscultates the abdomen of a client with a suspected paralytic ileus for 5 minutes5\text{ minutes} before proceeding to light palpation.

Answer

The observation requiring immediate intervention is the client with a right total hip arthroplasty resting with the right leg internally rotated.
Following a total hip arthroplasty utilizing a posterior approach, the client is at a highly elevated risk for prosthesis dislocation. To reduce this risk, the hip must be maintained in a state of abduction and neutral alignment. Internal rotation, adduction across the midline, and flexion past 90∘90^\circ are strictly contraindicated. The charge nurse must intervene immediately to reposition the leg, typically utilizing an abductor pillow, to prevent a severe physiological complication.

Step-by-Step Solution

1
Analyze the client with the total hip arthroplasty.
The leg is internally rotated.
Following a posterior approach, adduction and internal rotation dramatically increase the risk of the femoral head popping out of the acetabulum (dislocation).
2
Evaluate the client with peripheral arterial disease (PAD).
Legs are positioned dependently.
Dependent positioning uses gravity to enhance arterial blood flow to oxygen-starved tissues in PAD. This is a therapeutic position.
3
Assess the client with severe emphysema.
Oxygen saturation is 89%89\%.
Clients with chronic hypercapnia rely on mild hypoxemia to drive their respiratory effort. A saturation of 88%88\% to 92%92\% is the expected and safe target.
4
Review the abdominal assessment sequence.
Auscultation is performed for 5 minutes5\text{ minutes} before palpation.
Palpating before auscultating can stimulate peristalsis and create false bowel sounds. Listening for 5 minutes5\text{ minutes} is required to confirm an ileus.

Key Concept

Prevention of post-operative joint dislocation
Estimated Time:1m 0s
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic