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 D
Explanation
A. A protective environment is not necessary; Clostridium difficile requires contact precautions.
B. Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.
C. Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.
D. Disinfecting equipment daily helps reduce the risk of C. difficile spore transmission within the environment.
Correct Answer is C
Explanation
A. Widening pulse pressure is more indicative of increased intracranial pressure or septic shock, not hypovolemic shock.
B. Deep tendon reflexes are typically not increased in hypovolemic shock.
C. Increased heart rate is a compensatory response to hypovolemic shock as the body attempts to maintain cardiac output.
D. A pulse oximetry reading of 96% would not typically indicate hypovolemic shock; decreased oxygen saturation is more consistent with hypoxia.
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