A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Discontinue the overhead trapeze.

Turn the client every 6 hr while in bed.

Remind the client that phantom limb pain does not need treatment.

Assist the client to a prone position every 3 hr.

Answer and Explanation

The Correct Answer is D

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

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Correct Answer is D

Explanation

A) Restrict fluids to decrease lower extremity swelling: Restricting fluids is generally not recommended for managing peripheral arterial disease (PAD). Fluid restriction may not address the underlying vascular issues causing swelling and might lead to dehydration. The focus should be on improving circulation and managing PAD symptoms.

B) Limit exercise to 10 min twice a day: Exercise is a critical component of managing PAD, and limiting it to only 10 minutes twice a day may not provide sufficient benefit. Patients with PAD are often encouraged to engage in regular, supervised exercise programs to improve circulation and reduce symptoms.

C) Use ice packs to decrease leg pain: Using ice packs is not advisable for PAD. Cold can constrict blood vessels and potentially worsen symptoms. Warmth or gentle heat may be more beneficial for improving circulation and relieving pain.

D) Sit with legs dependent when having pain: Sitting with the legs dependent (hanging down) can help alleviate pain associated with PAD. This position helps increase blood flow to the lower extremities and can reduce pain caused by intermittent claudication, a common symptom of PAD.

A. Ask the client how she feels about her understanding of diabetes. B. Ask the client how often she reads food labels. C. Ask the client to explain what she read from a brief handout about diabetes management. D. Ask the client when she last had her HbA1c checked.

Correct Answer is C

Explanation

A) Asking the client how she feels about her understanding of diabetes can provide some insight into her confidence and perceived knowledge. However, it does not objectively measure her actual understanding or ability to apply diabetes management information.

B) Asking the client how often she reads food labels assesses a specific behavior related to diabetes management but does not fully evaluate the client's overall health literacy. The frequency of reading food labels may indicate some level of engagement, but it does not necessarily reflect comprehensive understanding or effective diabetes self-management.

C) Requesting the client to explain what she read from a brief handout about diabetes management provides a direct assessment of her comprehension and retention of diabetes management information. This approach effectively measures her ability to understand and apply critical health information, which is a core component of health literacy.

D) Inquiring about the timing of her last HbA1c test assesses adherence to diabetes monitoring but does not gauge the client's understanding of diabetes management. While important, this question does not provide a clear picture of her health literacy or ability to manage her condition effectively.

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A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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