A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg.
Which physician’s order should the nurse implement?

Administer morphine 2-4 mg IV prn for pain.

Apply a figure of 8 pressure dressing starting day two post-operatively.

Administer antibiotics as prescribed.

Apply ice to the stump for 60-90 minutes.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.

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Correct Answer is A

Explanation

Choice A rationale

Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.

Choice B rationale

+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.

Choice C rationale

A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.

Choice D rationale

A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.

A. 0640 B. 0650 C. 0700 D. 0710

Correct Answer is A

Explanation

The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404

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A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician’s order should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse gives a client 10 units of insulin lispro at 0630. When should the client have breakfast?

Correct Answer is A

Explanation

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A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg.
Which physician’s order should the nurse implement?