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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Findings that require follow-up:
- Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
- Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
- Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
- Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.
Correct Answer is B
Explanation
A. "I will take my child's rectal temperature daily.": Taking a rectal temperature in a child receiving chemotherapy is not recommended because it increases the risk of rectal injury and infection. An oral or axillary temperature is preferred.
B. "I will make sure to inspect my child's mouth every day for sores." Chemotherapy suppresses the immune system, leaving the child vulnerable to infections such as mucositis. Inspecting the mouth daily is crucial to detect any sores or signs of infection early and prevent complications.
C. "I will make sure my child gets their MMR vaccine this week.": Live vaccines like the MMR (measles, mumps, rubella) vaccine should not be given during chemotherapy or other forms of immunosuppressive treatment.
D. "I will ensure my child exercises a little each day by riding their bicycle.": Exercise may be limited during chemotherapy due to fatigue and increased susceptibility to infection. Physical activity should be tailored to the child's ability and energy level, not mandated.
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