A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?

Elevate the residual limb on a soft pillow.

Assist the client to a prone position every 4 hr.

Reapply a bandage to the residual limb every 12 hr.

Apply dressings to the site in a proximal-to-distal direction.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.

Choice B reason: This is the correct action, because assisting the client to a prone position every 4 hr can prevent hip flexion contractures and promote the range of motion of the hip joint. The client should lie prone for 20 to 30 minutes at a time, with the residual limb extended.

Choice C reason: This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.

Choice D reason: This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to

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Correct Answer is A

Explanation

Choice A reason:Option Ais correct. NSAIDs like ibuprofen arecommonly prescribedfor SLE-related joint pain and inflammation, provided there are no contraindications (e.g., renal impairment). The client’s statement reflects appropriate understanding of symptom management.

Choice B reason: This is an incorrect statement, because SLE is a systemic autoimmune disease that can affect multiple organs and tissues, not just the skin. The client may experience symptoms such as rash, arthritis, nephritis, anemia, or pericarditis.

Choice C reason:Option Cis incorrect. SLE patients requirerigorous sun protection(SPF ≥30) to prevent UV-induced flares. SPF 15 is insufficient, indicating inadequate teaching.

Choice D reason: This is an incorrect statement, because a mild fever can indicate an infection or a flare-up of SLE, which can require medical intervention. The client should monitor the temperature and report any fever or signs of infection to the provider.

A. A client who has benign prostate hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

Correct Answer is C

Explanation

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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