A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

Turn the client every 4 hr while in bed.

Place the client on an air mattress.

Instruct the client to use an overbed trapeze to move around in bed.

Rewrap the bandage every 8 hr in a circular pattern.

Answer and Explanation

The Correct Answer is C

A. Turning the client every 4 hours is too infrequent for a postoperative patient. The client should be turned at least every 2 hours to prevent complications such as pressure injuries.
B. An air mattress may help prevent pressure ulcers, but it does not specifically address postoperative care for an amputation.
C. Using an overbed trapeze allows the client to move independently, reducing strain on the residual limb and promoting mobility while preventing pressure injuries.
D. The bandage should be rewrapped every 4 to 6 hours in a figure-eight pattern, not every 8 hours in a circular pattern, to promote proper shaping of the residual limb and prevent circulation issues.

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Correct Answer is D

Explanation

A. Lubricating the catheter with water-soluble gel is important but is done after preparing the sterile field.
B. Attaching a prefilled syringe to the catheter inflation hub is performed after insertion to secure the catheter, not before.
C. Cleansing the client’s meatus with antiseptic solution is essential for infection prevention but is done after the sterile field is set up.
D. Positioning the sterile drape while leaving the perineum exposed is the first step because it maintains a sterile field and provides a clean working area for catheter insertion. This prevents contamination and reduces the risk of infection.

A. Establish a new routine for the child to follow while in the facility. B. Use medical terminology when discussing procedures with the child. C. Encourage the child to play with toys such as a pounding board. D. Perform the morning assessments when the parent is not in the room.

Correct Answer is C

Explanation

A. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.

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A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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