A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it:

prevents bleeding and covers the incision.

decreases phantom limb pain.

limits the formation of blood clots.

shapes the soft tissue and minimizes edema.

Answer and Explanation

The Correct Answer is D

A.   While wrapping the stump can help secure a dressing and protect the incision, the primary purpose of the elastic bandage is not to prevent bleeding. Instead, it helps to manage swelling and shape the residual limb.
B.   Phantom limb pain is a sensation where individuals feel pain in the area where the limb once was. While some patients report relief from phantom pain with various techniques, wrapping the stump is not specifically designed for this purpose. Other interventions are more effective for managing phantom limb pain.
C.   Elastic bandaging does not specifically limit the formation of blood clots in the context of an amputation stump. While proper limb positioning and movement can help prevent clot formation, the main purpose of the bandage is not related to clot prevention.
D.   The primary purpose of wrapping the stump with an elastic bandage is to shape the soft tissue and control edema (swelling). Proper compression helps reduce swelling, encourages the soft tissue to conform to the desired shape for fitting a prosthesis later, and aids in healing.

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Correct Answer is C

Explanation

A. While taking vital signs can provide useful information about the client's overall condition, it does not directly address the immediate concern of potential hypoglycemia. The priority is to assess blood glucose levels, as this will guide further actions.
B. Glucagon is used for severe hypoglycemia when the client is unable to consume glucose orally. However, before administering glucagon, it is essential to confirm hypoglycemia by checking the blood glucose level. This ensures that glucagon is only used when absolutely necessary.
C. Checking the blood glucose level will quickly determine whether the client is experiencing hypoglycemia. If the blood glucose is low, appropriate treatment (such as administering glucose or a fast-acting carbohydrate) can be initiated. If it’s within normal limits, other potential causes for the symptoms can be explored.

D. While it may be necessary to notify the physician depending on the outcome of the blood glucose reading or if the client’s condition worsens, it is not the first action. Immediate assessment of blood glucose is essential to determine the appropriate course of action.

A. Test a sample of urine for the presence of occult blood B. Check the client's weight C. Instruct the client to increase his water intake D. Review results of liver function studies

Correct Answer is D

Explanation

A. While testing for occult blood can help rule out hematuria (blood in the urine), it’s not the immediate priority. Dark urine could be related to several factors, including dehydration or changes in liver function, making this not the best first step.
B. While monitoring weight is important, it doesn't directly address the issue of dark urine. Weight changes might indicate fluid retention or loss but are not as immediately relevant to the urine color change.
C. Increasing water intake can help dilute the urine and may help with hydration. However, before suggesting this, it's important to understand the underlying cause of the urine change.
D. Glipizide and other sulfonylureas can affect liver function, and dark urine can indicate potential liver issues, such as bilirubinuria (bilirubin in the urine). Reviewing liver function studies would provide critical information to assess if the change in urine color is related to liver dysfunction or other serious issues.

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A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:

Correct Answer is C

Explanation

The client who has been taking glipizide for 6 months reports to the nurse that his urine has become darker since starting the medication. What is the nurse's first action?

Correct Answer is D

Explanation

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