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 B

Explanation

A) Drink cold beverages to increase peristalsis: While hydration is important for overall health, drinking cold beverages specifically is not a well-supported method for increasing peristalsis. The key to avoiding constipation is adequate fluid intake, but it doesn't need to be cold.

B) Increase daily water intake: Increasing daily water intake is a fundamental and effective strategy to prevent constipation. Adequate hydration helps soften the stool, making it easier to pass and promoting regular bowel movements.

C) Take a daily laxative to soften stools: Relying on a daily laxative is not recommended for long-term management of constipation as it can lead to dependence and disrupt normal bowel function. Dietary and lifestyle changes are preferred for preventing constipation.

D) Eat a low-residue diet: A low-residue diet, which is low in fiber and roughage, is typically used for specific medical conditions and may contribute to constipation rather than prevent it. To avoid constipation, a high-fiber diet is usually recommended to promote healthy bowel movements.

A. Herpes zoster B. Dermatophytosis C. Contact dermatitis D. Cellulitis

Correct Answer is D

Explanation

A) Herpes zoster
This condition, also known as shingles, is characterized by a painful, blistering rash that follows a nerve path. It typically presents as grouped vesicles rather than generalized edema and erythema, making it unlikely in this case.

B) Dermatophytosis
Commonly known as ringworm, this fungal infection usually causes a scaly, ring-shaped rash. It does not typically present with significant edema or erythema as seen with cellulitis, and tenderness is less common.

C) Contact dermatitis
This allergic or irritant reaction usually causes itching, redness, and rash after contact with a substance. While it can cause erythema and pain, it is less likely to cause the significant edema and tenderness observed in cellulitis.

D) Cellulitis
Cellulitis is a bacterial skin infection characterized by edema, erythema, tenderness, and pain. These symptoms align with the nurse’s findings, indicating an inflammatory response in the deeper layers of the skin, often requiring antibiotic treatment.

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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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Explanation

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Correct Answer is D

Explanation

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