Soru

Zorluk: OrtaBasic Care and Comfort

A nurse is creating a plan of basic care and comfort for a 78-year-old client who is 24 hours postoperative following a right total knee arthroplasty (TKA). Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

  1. A
    Place a thick pillow directly underneath the right knee to minimize joint tension.
  2. Administer prescribed oral analgesics 30 to 45 minutes before scheduled physical therapy sessions.Cevap
  3. Apply cold packs to the right knee as prescribed to help reduce localized swelling and pain.Cevap
  4. D
    Delegate the initial morning assessment of the right pedal pulse and capillary refill to the unlicensed assistive personnel (UAP).
  5. Instruct the client to perform continuous ankle dorsiflexion and plantar flexion exercises while resting in bed.Cevap
  6. F
    Inform the family that the client's sudden onset of acute confusion is a normal, expected part of the aging process following surgery.

Cevap

The correct interventions are administering analgesics before physical therapy, applying cold packs to the knee, and instructing the client to perform ankle pump exercises.
Appropriate basic care and comfort for a post-TKA client includes proactive pain management (administering analgesics prior to painful activities like physical therapy), non-pharmacologic symptom management (applying cold packs to reduce edema and pain), and promoting safe mobility (performing ankle exercises in bed to prevent venous stasis).

Adım Adım Çözüm

1
Analyze the client's clinical situation and postoperative needs.
The client is an older adult, 24 hours post-TKA, requiring pain management, mobility support, and complication prevention.
Understanding the surgical procedure and timeline dictates appropriate basic care and comfort interventions.
2
Evaluate each intervention for safety, efficacy, and appropriate scope of practice.
Analgesics prior to activity, cold application, and ankle exercises are safe and promote comfort/recovery. Pillows under the knee, delegating assessments, and normalizing acute confusion are unsafe practices.
Evidence-based practice guidelines dictate specific positioning and delegation rules to prevent complications like contractures, missed deterioration, and deep vein thrombosis.
3
Select all options that represent correct, safe nursing actions.
The options involving pre-medication, cold therapy, and ankle exercises are selected.
These actions directly support the objective of providing basic care and comfort while maintaining physiological integrity.

Anahtar Kavram

Basic postoperative care and comfort following joint arthroplasty requires balancing pain management, mobility promotion, and the prevention of surgical complications without delegating core nursing assessments.
Bu soruyu puanla