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
Localized pain at the injection site is a common, non-severe post-vaccination response caused by the body's immune reaction to the antigen. It indicates a normal inflammatory process and does not require immediate intervention unless it worsens or is accompanied by systemic symptoms.
Choice B rationale
A temperature of 100.7°F is categorized as a low-grade fever, often resulting from an immune response to vaccination. This is a benign and expected reaction, not requiring urgent medical attention unless the fever persists or rises significantly.
Choice C rationale
Swelling around the eyelids and mouth suggests a possible anaphylactic reaction, a severe allergic response to the vaccine. This condition requires immediate attention, as it may progress to airway obstruction or systemic involvement if untreated. Epinephrine administration and emergency measures are often necessary.
Choice D rationale
Decreased appetite is a mild and expected side effect post-vaccination due to temporary discomfort or systemic immune activation. This reaction generally resolves on its own and does not necessitate prioritization unless it significantly impacts hydration or nutrition over an extended period.
Correct Answer is A
Explanation
Choice A rationale
Elevated total protein in cerebrospinal fluid suggests increased inflammation and permeability of the blood-brain barrier due to bacterial meningitis. Proteins, primarily immunoglobulins, leak into CSF during infection. Normal CSF protein levels range from 15-45 mg/dL, and significant elevation indicates pathological changes consistent with bacterial involvement.
Choice B rationale
Decreased white blood cells contradict bacterial meningitis, as infection prompts immune response elevation. Elevated WBCs, typically neutrophils, indicate the body’s defense against bacterial pathogens. Normal CSF WBC range is 0-5 cells/µL, and deviations confirm meningitis diagnosis.
Choice C rationale
Decreased pressure in CSF indicates other neurological conditions rather than bacterial meningitis. Bacterial infections often increase intracranial pressure due to inflammation and fluid buildup, aligning with typical diagnostic findings.
Choice D rationale
Elevated glucose in CSF contradicts bacterial meningitis diagnosis. Bacteria consume glucose, leading to low CSF glucose levels relative to blood glucose. Normal CSF glucose levels range from 40-70 mg/dL, and reduction suggests bacterial growth and metabolic activity. .
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