A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Restrict visitors to family members until the client is able to wear a prosthesis.

Encourage the client to talk with another client who completed rehabilitation for amputation.

Instruct the client to ignore phantom pain sensations.

Suggest that family members bring clothing for the client from home.

Ask the client to describe her feelings about the loss of the affected limb.

Answer and Explanation

Correct Answer : B,D,E

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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Correct Answer is B

Explanation

A. Hct: Hematocrit measures red blood cell concentration but is not directly affected by warfarin therapy.
B. INR: The international normalized ratio (INR) is the key lab value to monitor in clients taking warfarin, as it reflects the drug’s effect on blood clotting and helps ensure the dose is therapeutic (target INR typically 2-3 for atrial fibrillation).
C. BUN: Blood urea nitrogen assesses kidney function and is unrelated to warfarin monitoring.
D. LDL: Low-density lipoprotein levels assess cardiovascular risk but are not affected by warfarin.

A. Current medication prescriptions B. Primary health problem C. Number of family members who have visited D. Admission vital signs from 1 week ago E. Scheduled times for dressing changes

Correct Answer is ["A","B","E"]

Explanation

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

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A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?

Correct Answer is B

Explanation

A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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