A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

Elevate the child's residual limb for 48 hr.

Apply a loose-fitting bandage onto the child's residual limb.

Perform active and isotonic range-of-motion exercises.

Clean the incision using half-strength hydrogen peroxide every 8 hr.

Answer and Explanation

The Correct Answer is C

A. Elevate the child's residual limb for 48 hr. Elevation for prolonged periods can cause flexion contractures. Elevation is typically limited to the first 24 hours, if at all.
B. Apply a loose-fitting bandage onto the child's residual limb. A compression bandage, not loose-fitting, is used to shape the residual limb and reduce swelling.
C. Perform active and isotonic range-of-motion exercises. These exercises prevent contractures and maintain muscle strength.
D. Clean the incision using half-strength hydrogen peroxide every 8 hr. Hydrogen peroxide can damage healthy tissue and delay healing. Saline or antiseptic solutions are preferred.

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Correct Answer is A

Explanation

A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.

A. "I can offer popcorn as a snack food." B. "I will make sandwiches on rye bread." C. "I will purchase graham crackers to pack in their lunchbox." D. "I can make beef barley soup for dinner."

Correct Answer is A

Explanation

A. "I can offer popcorn as a snack food." Popcorn is gluten-free and safe for children with celiac disease.
B. "I will make sandwiches on rye bread." Rye contains gluten and should be avoided.
C. "I will purchase graham crackers to pack in their lunchbox." Graham crackers often contain gluten and are unsuitable unless specifically labeled gluten-free.
D. "I can make beef barley soup for dinner." Barley contains gluten and is not safe for children with celiac disease.

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A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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