An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?
a. Administer mild sedation.
b. Keep all four siderails up.
c. Restrain the client's hands.
d. Use an abduction pillow.
ANS: D
Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.
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