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Zorluk: OrtaBasic Care and Comfort

A nurse is planning care for an older adult client who is 48 hours post-operative following a right total hip arthroplasty (posterior approach). The client requires assistance with daily activities, and the nurse is coordinating care with an unlicensed assistive personnel (UAP). Which of the following interventions should the nurse include in the client's plan of care to promote comfort and safety? (Select all that apply)

  1. Place an abduction pillow between the client's lower extremities while turning them in bed.Cevap
  2. Utilize a fracture bedpan for elimination to minimize lifting of the client's pelvis.Cevap
  3. C
    Elevate the head of the bed to a 90-degree angle when assisting the client with meals.
  4. D
    Delegate the comprehensive skin assessment under the anti-embolism stockings to the UAP.
  5. Apply a prescribed ice pack to the incisional area for 20-minute intervals to manage localized swelling.Cevap
  6. F
    Document the client's new onset of sudden confusion as a normal, expected physiological response to hospitalization.

Cevap

The nurse should place an abduction pillow between the legs, utilize a fracture bedpan, and apply prescribed ice packs to the incision.
The correct interventions focus on maintaining essential surgical precautions (abduction to prevent crossing the midline, avoiding excessive flexion via a fracture bedpan) and utilizing safe non-pharmacological pain management (cold therapy) to optimize the client's postoperative comfort and structural integrity.

Adım Adım Çözüm

1
Identify the surgical procedure and its specific physiological restrictions.
The client had a right total hip arthroplasty (posterior approach), meaning hip flexion greater than 90 degrees, adduction, and internal rotation must be avoided to prevent dislocation.
Understanding surgical precautions dictates safe mobility and positioning interventions.
2
Evaluate each intervention for safety, appropriate delegation, and comfort promotion.
Abduction pillows and fracture bedpans respect hip precautions. Ice packs provide non-pharmacologic pain relief. Sitting at 90 degrees violates precautions. Delegating assessment and ignoring confusion violate nursing standards.
Basic care and comfort must be balanced with safe practice guidelines and accurate clinical judgment.
3
Select the appropriate nursing interventions.
The correct interventions are maintaining abduction, using a low-profile bedpan, and applying localized cold therapy.
These actions directly promote comfort while maintaining physiological integrity and safety.

Anahtar Kavram

Basic care and comfort measures for a post-operative client must strictly adhere to specific surgical precautions (e.g., hip precautions) and standard nursing principles regarding delegation and acute status changes.
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Basic Care and Comfort

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