A nurse is collecting data from a client who is postoperative from a below-the-knee amputation and whose residual limb is wrapped with an elastic bandage to shrink the stump.
Which of the following findings should alert the nurse to a possible complication?
The dressing forming a cone shape over the stump.
Looseness of the stump dressing.
Pitting edema above the bandage.
Figure-eight wrapping around the stump.
The Correct Answer is C
Choice A rationale
A dressing that forms a cone shape over the residual limb is generally considered a desirable outcome for a post-amputation stump. This shape is achieved through specific wrapping techniques to facilitate the shrinking and molding of the limb for future prosthetic fitting. It helps ensure that the distal end of the limb is narrower than the proximal portion. This is a standard therapeutic goal and does not indicate a complication that requires urgent nursing intervention.
Choice B rationale
Looseness of the stump dressing is a common occurrence as the initial post-operative edema begins to subside. While the nurse should rewrap the limb to maintain consistent pressure and continue the molding process, mild looseness is not usually a sign of an acute complication like ischemia or hemorrhage. The nurse should monitor the limb for changes in size and ensure the bandage is snug enough to provide support without cutting off the arterial blood supply.
Choice C rationale
Pitting edema observed above the bandage is a significant finding that suggests the elastic wrap is applied too tightly or is creating a tourniquet effect. This obstructs venous return and lymphatic drainage from the distal portion of the limb. Edema can lead to tissue ischemia, delayed healing, and skin breakdown. The nurse must recognize this as a sign of impaired circulation. Normal skin should be non-pitting, and any indentation indicates fluid accumulation in the interstitial spaces.
Choice D rationale
The figure-eight wrapping technique is the preferred method for applying an elastic bandage to a residual limb. This method provides even pressure distribution, avoids circular constriction that could impede blood flow, and helps mold the stump into the necessary shape for a prosthesis. Because this is the correct and standard procedure for stump care, it is not a finding that would alert the nurse to a complication. It demonstrates proper nursing practice and limb management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a skin biopsy can provide histological information about the layers of the skin, it is not the primary or most common method for identifying the specific pathogenic microorganisms causing cellulitis. Biopsies are invasive and usually reserved for cases where the diagnosis is uncertain or if a fungal or unusual infection is suspected. In standard bacterial cellulitis, the results from a biopsy may not yield a clear culture due to the diffuse nature of the infection.
Choice B rationale
An MRI scan is a sophisticated imaging tool used to visualize soft tissue structures, but it cannot identify the specific bacterial species causing an infection. It is highly useful for detecting deep-seated complications like abscesses or necrotizing fasciitis by showing edema and fluid collections. However, because it provides anatomical rather than microbiological data, it does not guide targeted antibiotic therapy based on the sensitivity of a particular pathogen to various pharmacological agents.
Choice C rationale
X-ray imaging is primarily used to rule out other conditions such as a fracture or to check for gas in the tissues, which could indicate a more severe infection like gas gangrene. It does not have the capability to visualize bacteria or identify the microbial cause of cellulitis. X-rays are generally insensitive for early soft tissue infections and provide no information regarding the specific pathogen's identity or its susceptibility to various types of medical treatments.
Choice D rationale
Blood cultures are a critical diagnostic tool when cellulitis is severe or associated with systemic signs of infection like fever or chills. Identifying pathogens in the blood helps confirm the causative agent and its antibiotic sensitivity, which is vital for effective treatment. Although skin surface swabs are often contaminated with normal flora, a positive blood culture provides definitive evidence of the specific bacteria, such as Staphylococcus aureus, circulating in the patient's system.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Hydration is fundamental for maintaining the structural integrity of the skin and supporting the proliferative phase of wound healing. Proper fluid intake ensures that the dermis remains turgid, which facilitates the transport of essential nutrients and oxygen to the surgical site. This biological support helps in the synthesis of collagen and prevents the skin from becoming brittle or susceptible to further breakdown or secondary irritation during the recovery period.
Choice B rationale
Monitoring for infection is a critical nursing priority because redness, warmth, and itching are early clinical indicators of a localized inflammatory response or bacterial colonization. The nurse must assess for purulent drainage and systemic signs like a temperature greater than 100.4 degrees Fahrenheit. Early detection of pathogens prevents sepsis and ensures that the tissue repair process is not stalled by the presence of microorganisms that consume cellular energy and oxygen.
Choice C rationale
Prolonged sun exposure is contraindicated after dermatologic surgery because ultraviolet radiation causes DNA damage and triggers further inflammation in vulnerable, healing tissues. UV rays increase the risk of hyperpigmentation and can weaken the developing basement membrane. Protecting the surgical site from the sun ensures that the remodeling phase occurs without external thermal or radiation stress, which could lead to scarring or delayed primary intention closure of the wound.
Choice D rationale
Ignoring changes in skin color or temperature is a violation of standard nursing practice and patient safety protocols. These physiological changes serve as vital cues for complications such as hematoma formation, cellulitis, or impaired perfusion. A localized increase in temperature often signifies an active immune response or infection, while color changes can indicate venous congestion or arterial insufficiency. Consistent assessment is necessary to prevent permanent tissue necrosis and ensure optimal patient outcomes.
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