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.
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.
Choice B reason: This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.
Choice C reason: This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.
Choice D reason: This is the correct action, because placing the syringe in a puncture-proof disposal container can prevent accidental injuries and infections, and comply with the local regulations for sharps disposal.
Correct Answer is B
Explanation
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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