During hourly overnight rounds on a surgical unit, a practical nurse observes an older adult client who is recovering from a recent right total hip arthroplasty. The client, who has a history of transient confusion, is agitated, attempting to exit the bed unassisted, and actively crossing their right leg over their left leg. Which intervention is the priority for the nurse to implement to prevent a severe complication?
- AElevate the head of the bed to a high-Fowler's (90-degree) position to help the client feel less confined and reduce their agitation.
- Position an abduction pillow between the client's legs and gently assist them back into a supine resting position.Cevap
- CSecure bilateral soft wrist restraints to the movable portion of the bed frame to immediately stop the client from falling.
- DQuickly administer the client's prescribed as-needed sedative medication without completing the standard identification verification process.
Cevap
Position an abduction pillow between the client's legs and gently assist them back into a supine resting position.
Following a total hip arthroplasty, it is critical to maintain the affected leg in a state of abduction to prevent the prosthesis from dislocating. When the client crosses their legs, they are adducting the hip, which creates an immediate risk for a severe dislocation injury. Using an abduction pillow corrects the alignment safely, while gently assisting the client back to a supine position addresses the fall risk without resorting to chemical or physical restraints.
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Anahtar Kavram
Postoperative Positioning and Injury Prevention