A nurse is preparing for a home visit with a client who is postoperative following an above-the-knee amputation. Which of the following questions should the nurse plan to ask first?

"Have you scheduled an appointment with the prosthetist?"

"Do you feel your pain is controlled well?

"Are you aware of any support groups in the area?"

"Have you been exercising your other extremities?"

Answer and Explanation

The Correct Answer is B

A. While scheduling an appointment with the prosthetist is important, the client's comfort and pain control take precedence, especially in the immediate postoperative period. Addressing pain concerns is a priority to ensure the client's well-being.

B. "Do you feel your pain is controlled well?" is the first question to ask. Assessing pain is crucial to understanding the client's level of comfort and ensuring that appropriate measures are in place for pain management. This information can guide further interventions and adjustments to the care plan.

C. Inquiring about support groups in the area is an important aspect of the client's overall well-being and adjustment to the amputation. However, pain control is an immediate concern, and addressing it takes precedence during the initial home visit.

D. Asking about exercising other extremities is relevant for the client's overall mobility and

rehabilitation. However, pain control assessment should be prioritized as it directly impacts the client's ability to participate in rehabilitation activities.

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Correct Answer is A

Explanation

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

A. Report the occurrence to the nursing supervisor, B. Complete an incident report stating the facts of the situation. C. Verify the DNR prescription is current in the medical record. D. Request a meeting with the ethics committee.

Correct Answer is C

Explanation

A. Report the occurrence to the nursing supervisor:

While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.

B. Complete an incident report stating the facts of the situation:

Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.

C. Verify the DNR prescription is current in the medical record.

Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.

D. Request a meeting with the ethics committee:

Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.

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A nurse is preparing for a home visit with a client who is postoperative following an above-the-knee amputation. Which of the following questions should the nurse plan to ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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