A client undergoes an above-the-knee amputation (AKA) of the right leg because of peripheral vascular disease. On the second postoperative day, the nurse enters the room to take the client's vital signs and finds the client lying in a prone position. The client asks for assistance in turning. Which action should the nurse take first?
Determine how long the client has been lying prone.
Measure the client's vital signs.
Inspect the dressing on the stump.
Assist the client in turning to a position of comfort.
The Correct Answer is A
A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.
B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.
C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.
D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.
B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.
C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.
D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.
Correct Answer is A
Explanation
A. Maintain strict intake and output: Maintaining strict intake and output is essential in septic shock to monitor renal function and ensure adequate perfusion. Decreased urine output can indicate worsening shock or kidney failure, which requires prompt intervention.
B. Assess warmth of extremities: Early signs of septic shock often include cool or mottled extremities due to poor circulation, which should be addressed more through perfusion monitoring than by focusing solely on warmth.
C. Keep head of bed raised 45 degrees: Elevating the head of the bed may be helpful in certain situations, but it is not the most critical intervention for septic shock. The priority is to ensure proper hemodynamic monitoring, fluid resuscitation, and organ perfusion.
D. Monitor blood glucose level: While monitoring blood glucose is important in critically ill clients, it is not the immediate priority in septic shock. Sepsis often causes hyperglycemia, but managing fluid resuscitation and organ perfusion is the most urgent intervention.
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