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 A
Explanation
Choice A rationale
Allowing medications to flow by gravity ensures gradual administration, minimizing the risk of mucosal irritation and preventing excessive pressure or leakage in the nasogastric tube.
Choice B rationale
Crushing sustained-release tablets alters their pharmacokinetics, leading to uncontrolled drug release and increased risk of toxicity or subtherapeutic effects. Sustained-release formulations must remain intact.
Choice C rationale
Using 2 mL sterile water is inadequate for flushing a nasogastric tube post-medication; recommended flushing volumes typically range between 10-15 mL for effective clearance.
Choice D rationale
Mixing medications together may result in chemical interactions and altered bioavailability. Administering each medication individually is essential to maintaining integrity and therapeutic efficacy.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Obtaining daily weights is vital for monitoring fluid status and nutritional health, especially in children prone to rapid physiological changes. It provides insight into trends such as dehydration, edema, or growth concerns.
Choice B rationale
Blood pressure every 8 hours is a less frequent monitoring intervention and may not be sufficient for detecting acute changes. Vital signs often require more regular assessment in pediatric care.
Choice C rationale
Maintaining seizure precautions ensures immediate response readiness for children with neurological risks or past seizure history. It involves safeguards like padded bed rails and accessible emergency equipment to mitigate injury risks during seizures.
Choice D rationale
Sodium-restricted diets are less commonly applied in pediatric cases unless specifically indicated for conditions like nephrotic syndrome or severe hypertension. Routine care does not involve universal dietary sodium modifications.
Choice E rationale
Strict bed rest may lead to deconditioning and is only suitable for specific diagnoses necessitating immobility. Pediatric care often promotes movement within safe limits to prevent complications like pressure injuries.
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