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Zorluk: Çok zorBasic Care and Comfort

A practical nurse (PN) is assisting an older adult client with morning hygiene and elimination. The client is 2 days postoperative following a right total hip arthroplasty (posterior approach) and requires strict adherence to hip precautions. Which of the following actions by the PN are appropriate? (Select all that apply.)

  1. Roll the client toward the unaffected side with an abduction wedge securely in place between the legs to wash the back.Cevap
  2. B
    Instruct the client to flex the right hip to 110 degrees to allow for easier placement of a standard bedpan.
  3. Place a fracture pan under the buttocks while the client uses an overhead trapeze bar to assist with lifting.Cevap
  4. D
    Maintain the bed in a completely flat, supine position while assisting the client with their morning meal to avoid hip flexion.
  5. Wash the client's eyes from the inner canthus to the outer canthus, using a different section of the washcloth for each wipe.Cevap
  6. F
    Apply bilateral soft wrist restraints immediately if the client becomes disoriented and begins pulling at the surgical dressing.

Cevap

The appropriate actions are to roll the client toward the unaffected side with an abduction wedge, use a fracture pan combined with an overhead trapeze bar, and wash the eyes from the inner to the outer canthus.
The appropriate actions prioritize joint safety, airway management, and infection control. Using an abduction wedge when turning to the unaffected side prevents dangerous hip adduction. Utilizing a fracture pan with a trapeze bar minimizes hip flexion during elimination. Finally, washing the eyes from the inner to outer canthus adheres to standard hygiene principles to prevent eye infections.

Adım Adım Çözüm

1
Identify the client's specific physical limitations and safety requirements.
The client is 2 days postoperative for a right total hip arthroplasty (posterior approach) and requires strict adherence to precautions: no hip flexion greater than 90 degrees, no adduction, and no internal rotation.
Understanding surgical precautions is essential before initiating any physical movement or basic care.
2
Evaluate positioning techniques for hygiene tasks.
Rolling the client toward the unaffected side while utilizing an abduction wedge prevents adduction and internal rotation, making it a safe method to wash the back.
Maintaining neutral alignment of the operative leg prevents dislocation of the new hip joint.
3
Determine the safest method for assisting with elimination.
Utilizing a fracture pan requires less lifting, and having the client use an overhead trapeze bar allows them to raise their torso without excessive hip flexion.
A standard bedpan usually requires significant hip flexion and rolling, which violates posterior hip precautions.
4
Recall standard infection control principles for facial hygiene.
Washing the eyes from the inner canthus to the outer canthus using clean sections of the cloth is identified as the correct protocol.
This specific technique prevents the introduction of bacteria or debris into the lacrimal ducts.
5
Identify and exclude contraindicated or unsafe actions.
Flexing the hip to 110 degrees, feeding the client while completely flat, and immediately applying restraints are all rejected.
Hip flexion past 90 degrees violates orthopedic precautions, feeding while flat prioritizes joint precautions over immediate airway safety (aspiration risk), and applying restraints without alternatives violates safety protocols.

Anahtar Kavram

Safe execution of basic hygiene and elimination care while adhering to posterior total hip arthroplasty precautions and maintaining airway safety.
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Konular

Basic Care and Comfort

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