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Zorluk: KolayBasic Care and Comfort

A practical nurse is providing care for an older adult client who recently returned to the unit following a right total hip arthroplasty. The client appears restless, is newly confused, and is attempting to cross their legs. Which of the following is the most appropriate initial action by the nurse?

  1. Place an abductor pillow between the client's legs and verbally reorient the client.Cevap
  2. B
    Apply bilateral soft wrist restraints to prevent the client from disrupting the surgical site.
  3. C
    Document the confusion as an expected age-related change and continue routine observation.
  4. D
    Elevate the head of the bed to a high-Fowler's position to help the client clearly see the surroundings.

Cevap

Place an abductor pillow between the client's legs and verbally reorient the client.
After a total hip arthroplasty, it is critical to maintain the client's legs in an abducted position to prevent dislocation of the hip prosthesis. Placing an abductor pillow successfully prevents the client from crossing their legs. Furthermore, verbal reorientation is a standard, non-restrictive nursing intervention that provides comfort and addresses acute confusion safely.

Adım Adım Çözüm

1
Identify the immediate physical risk to the client.
The client is attempting to cross their legs, which places them at high risk for hip dislocation following a total hip arthroplasty.
Post-operative hip precautions require keeping the legs abducted (apart) and avoiding adduction (crossing).
2
Determine the most appropriate and least restrictive intervention.
Using an abductor pillow physical protects the hip alignment, while verbal reorientation safely addresses the confusion.
Nursing care prioritizes basic comfort, safety, and using the least restrictive interventions before considering restraints.

Anahtar Kavram

Postoperative safety and positioning for total hip arthroplasty
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Konular

Basic Care and Comfort

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