A client who is to have an amputation of the lower extremity asks the nurse. "How much of my leg will the doctor have to amputate?" The nurse's response is based on the knowledge that the level of amputation is determined by the:
ease with which a prosthesis can be fitted.
adequacy of the blood supply to the stump for healing.
need to remove as much of the leg as possible.
client's ability to walk with a prosthesis.
The Correct Answer is B
A. While the ease of fitting a prosthesis is a consideration, it is not the main factor. The level of amputation is primarily determined by medical considerations, particularly related to health and healing.
B. This is the primary determinant for the level of amputation. Surgeons aim to preserve as much limb length as possible while ensuring that the remaining tissue has adequate blood supply for healing.
Insufficient blood supply can lead to complications, including poor healing and infection, making this a critical factor in deciding the amputation level.
C. This option suggests a more aggressive approach than necessary. The goal is to remove only as much of the limb as required to address the medical issue (e.g., disease, trauma) while preserving as much healthy tissue as possible for optimal healing and function.
D. While a client’s functional ability with a prosthesis is an important consideration in rehabilitation planning, it is not the main factor in deciding the surgical level of amputation. The decision about how much limb to remove is made based on medical criteria, particularly healing potential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This option refers to the pathogens themselves (infectious agents) and the places where they live and multiply (reservoirs). Washing hands does not directly affect the relationship between these two.
B. The portal of exit refers to how an infectious agent leaves the reservoir (e.g., through feces, urine, etc.), and the mode of transmission refers to how the agent spreads (e.g., via hands, surfaces, etc.). Handwashing helps reduce the potential for pathogens to be transmitted but does not specifically break the chain between these two links.
C. Handwashing after using the bathroom effectively breaks the chain of infection by interrupting the mode of transmission (direct contact with contaminated hands) and preventing pathogens from entering another person's body (portal of entry). By cleaning hands, the risk of spreading infectious agents to others is significantly reduced.
D. This option refers to the relationship between a person who is vulnerable to infection (susceptible host) and the pathogens that cause disease (infectious agents). While handwashing helps prevent infections, it primarily acts on the transmission aspect rather than directly affecting susceptibility.
Correct Answer is ["A","C","E"]
Explanation
A. Lethargy can occur in DKA due to the effects of hyperglycemia, acidosis, and dehydration. Even if the client is oriented, confusion about the reason for care suggests an altered mental state, which can be common in DKA.
B. This ABG indicates alkalosis (pH > 7.45), which is not typical for DKA. In DKA, we would expect a lower pH (acidosis). This set of values does not align with the expected clinical picture of DKA.
C. This ABG shows a pH of 7.31, indicating acidosis. The low HCO3 (17) supports metabolic acidosis, which is characteristic of DKA. This finding is consistent with the expected laboratory results in a patient experiencing DKA.
D. A heart rate of 52 (bradycardia) is not a common finding in DKA. In fact, tachycardia (elevated heart rate) is typically observed due to dehydration and compensatory mechanisms. Bradycardia would not be expected in this context.
E. A respiratory rate of 31, particularly if deep (known as Kussmaul respirations), is a classic sign of metabolic acidosis, including DKA. Kussmaul respirations are the body’s attempt to compensate for acidosis by increasing carbon dioxide elimination.
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