A nurse is caring for a child who is 3 days postoperative following a below-the-knee amputation of the left leg.
Which of the following actions should the nurse take first?
Reinforce teaching about phantom limb pain to the child.
Inspect the skin at the incision site for manifestations of infection.
Perform range-of-motion exercises to the affected extremity.
Assist in placing the child in the prone position three times a day.
The Correct Answer is B
Choice A rationale
Phantom limb pain education is important but not an immediate priority. It focuses on post-amputation sensation caused by disrupted nerve signals. However, addressing complications like infection is crucial in the immediate postoperative phase to prevent further morbidity.
Choice B rationale
Inspecting the incision site prioritizes infection control. Early signs of infection such as erythema, warmth, or exudate must be addressed immediately to prevent systemic spread. Postoperative infections can impede healing and increase hospital stay. This action directly impacts the child's recovery.
Choice C rationale
Range-of-motion exercises are vital in the long-term rehabilitation phase to prevent contractures. However, these exercises do not address immediate concerns like postoperative infection, making them a secondary priority in acute care.
Choice D rationale
The prone position helps prevent hip flexion contractures in patients post-lower extremity amputation. While essential for long-term musculoskeletal health, this action is not the most critical during the acute recovery phase when infection is a larger concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Turning two pages at a time reflects fine motor control development seen in younger toddlers. At 15 months, most toddlers refine coordination, progressing to turning single pages. Double-page turning is less precise, often due to immature grasp and pinch abilities. Fine motor milestones evolve with age, allowing toddlers to handle books more adeptly. This finding contrasts expected skills of a 15-month-old toddler, who typically exhibits improved single-page manipulation.
Choice B rationale
Throwing a ball overhead without falling signifies advanced gross motor skills uncommon at 15 months. Toddlers this age generally develop basic motor coordination like walking and controlled ball rolling rather than overhead throwing. Overhead throwing requires integrated balance and muscle strength, milestones reached closer to 18-24 months. A 15-month-old’s motor development includes walking without assistance and simple gross motor activities like kicking.
Choice C rationale
Drinking independently from a cup indicates motor and cognitive skills typical of a 15-month-old toddler. At this age, toddlers develop hand-eye coordination and the ability to grasp and tilt cups correctly. Fine motor milestones include learning to feed themselves and achieve independence in activities like drinking. Drinking independently reflects self-sufficiency and developmental progress expected in toddlers at 15 months.
Choice D rationale
Referring to themselves by their first name reflects cognitive and language skills progressing beyond 15 months. Toddlers this age typically use single words or gestures to communicate needs. Self-identification with their name becomes evident later, around 18-24 months, as language skills improve. A 15-month-old toddler may recognize their name but is unlikely to articulate it spontaneously.
Correct Answer is D
Explanation
Choice A rationale
HbA1c testing does not measure oxygen-carrying capacity. Instead, that is assessed by the hemoglobin or oxygen saturation levels. HbA1c specifically evaluates glycosylated hemoglobin, indicating average blood glucose levels over time.
Choice B rationale
Testing for urinary ketones is a separate diagnostic test used to detect ketoacidosis, a complication of diabetes. HbA1c does not assess ketones but reflects long-term glycemic control by analyzing glucose bound to hemoglobin.
Choice C rationale
HbA1c does not measure total hemoglobin but rather the percentage of hemoglobin bound to glucose. Therefore, this test provides insight into blood sugar levels rather than the actual quantity of hemoglobin in the blood.
Choice D rationale
The HbA1c test reflects blood sugar control over the past 2-3 months by measuring the proportion of glycosylated hemoglobin. This provides a long-term overview of glucose management, crucial for optimizing treatment in diabetes mellitus.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.