A nurse is reinforcing discharge teaching with a client who had an above-the-knee amputation and has a prosthesis. Which of the following instructions should the nurse include?
"Keep initial pressure dressing in place for 1 week after surgery."
"Leave the prosthesis in place when going to bed."
"Avoid extension of the hips when lying down."
"Clean the prosthesis using a damp, soapy cloth."
The Correct Answer is D
Answer: D. "Clean the prosthesis using a damp, soapy cloth."
Rationale:
A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.
B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.
C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.
D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Ampicillin: Ampicillin is contraindicated for this client because it belongs to the penicillin class of antibiotics. Since the client is allergic to penicillin, administering ampicillin could trigger an allergic reaction, which could range from mild rash to severe anaphylaxis.
B) Erythromycin: Erythromycin is a macrolide antibiotic and can be used as an alternative for clients who are allergic to penicillin. It is often prescribed for group B streptococcus infections in penicillin-allergic clients, making it a suitable option in this case.
C) Cefazolin: Cefazolin is a cephalosporin antibiotic and is generally considered safe for clients with a penicillin allergy, except in cases of severe penicillin allergies. Cross-reactivity is low, and cefazolin can be an appropriate choice for treating group B streptococcus.
D) Clindamycin: Clindamycin is a lincosamide antibiotic and is often used for clients with penicillin allergies. It is effective against group B streptococcus and does not belong to the penicillin or cephalosporin classes, making it a suitable option for this client.
Correct Answer is C
Explanation
When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.
The other options are not correct because:
a) The client should not bear down during rectal tube insertion.
b) Administering a second enema if results are not clear is not mentioned as a safety precaution.
d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.
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