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 A
Explanation
A. Remind the client to keep his appointments to have his cholesterol level checked: Ezetimibe works by reducing cholesterol absorption in the intestines. Its effectiveness is best evaluated through changes in cholesterol levels, making lab tests crucial for monitoring its impact.
B. Teach the client to weigh himself weekly and keep a log of the measurements: While monitoring weight can be important for other conditions, it is not the primary evaluation for the effectiveness of ezetimibe, which targets cholesterol levels rather than body weight.
C. Encourage the client to keep a diary of his food intake until his next visit to the clinic: Although a food diary can be helpful for managing diet, the effectiveness of ezetimibe is best assessed through cholesterol levels rather than dietary tracking alone.
D. Assess the elasticity of the client's skin at the next scheduled clinic appointment: Skin elasticity is not directly related to the effectiveness of ezetimibe. This medication’s primary impact is on cholesterol levels, which should be monitored through lab tests.
Correct Answer is D
Explanation
A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.
B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.
C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.
D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.
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