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Zorluk: OrtaBasic Care and Comfort

A nurse is planning care for an older adult client who is recovering from a right total hip arthroplasty performed 24 hours ago. The client needs support with comfort measures and daily activities. Which of the following actions is the most appropriate for the nurse to implement?

  1. Place an abduction wedge between the client's lower extremities during turning and repositioning.Cevap
  2. B
    Place the client in a high-Fowler's position while preparing them to eat breakfast.
  3. C
    Assign the unlicensed assistive personnel (UAP) to evaluate the client's sacral area for signs of pressure injury.
  4. D
    Document the client's sudden onset of disorientation as an expected physiological response to aging.

Cevap

The most appropriate action is to use an abduction wedge between the client's legs when repositioning.
Placing an abduction wedge between the client's lower extremities prevents adduction of the operative hip. Following a total hip arthroplasty, maintaining the legs in a slightly abducted position is critical to prevent the prosthesis from dislocating.

Adım Adım Çözüm

1
Identify the client's surgical procedure and associated risks.
The client had a total hip arthroplasty, which carries a high risk of prosthetic dislocation if the hip is positioned incorrectly.
Recognizing postoperative restrictions is critical for determining safe basic care and mobility practices.
2
Analyze standard positioning precautions for this specific surgery.
Standard precautions dictate avoiding adduction (crossing legs), internal rotation, and hip flexion greater than 90 degrees.
These movements can force the femoral head out of the acetabular cup.
3
Evaluate each option against safe practice and nursing scope.
Using an abduction wedge is the only correct and safe action. High-Fowler's violates flexion limits, UAPs cannot perform assessments, and acute confusion requires immediate medical evaluation.
Eliminating actions that are contraindicated or outside the scope of practice isolates the correct evidence-based intervention.

Anahtar Kavram

Postoperative Positioning and Safe Basic Care
Tahmini Süre:1m 15s
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Konular

Basic Care and Comfort

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