A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Wrap the residual limb with an elastic bandage in a figure-eight configuration.
Wrap the residual limb with an elastic bandage in a proximal-to-distal direction.
Remove the elastic bandage and re-wrap the residual limb once a day.
Secure the elastic bandage to the lowest joint.
The Correct Answer is A
A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.
B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.
C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.
D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The location of burns on the face, neck, and upper extremities is critical as it can compromise the airway, making it a priority.
B. Age is important for overall risk assessment, but airway compromise takes precedence.
C. The cause of the burn (e.g., chemical, electrical) impacts treatment but is secondary to addressing airway risks in this scenario.
D. Associated medical history provides context but does not supersede the immediate concerns related to the burn location and airway.
Correct Answer is ["C","D","E"]
Explanation
A. Ecchymosis, or bruising, may be present but does not directly evaluate neurovascular status.
B. Skin integrity is important for general wound assessment but does not specifically indicate neurovascular function.
C. Sensation assessment helps evaluate nerve function, which is critical in identifying potential neurovascular compromise.
D. Color of the affected limb provides information on blood flow, with pale or cyanotic coloring suggesting potential compromise.
E. Temperature can indicate adequate blood flow; a cooler extremity may suggest poor circulation, indicating neurovascular compromise.
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