A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting.When the patient arrives on the orthopedic unit after surgery, which action should the nurse take?

Encourage the patient to bear weight on the residual limb to promote early ambulation.

Apply a tight compression bandage to the residual limb to promote circulation.

Assess the residual limb for signs of hemorrhage or poor circulation.

Remove the prosthetic limb and keep the residual limb uncovered to allow for air exposure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging the patient to bear weight on the residual limb immediately after surgery is not recommended due to the risk of injury and poor healing.

Choice B rationale

Applying a tight compression bandage can help with circulation, but assessing for complications takes precedence immediately after surgery.

Choice C rationale

Assessing the residual limb for signs of hemorrhage or poor circulation is crucial to identify any post-surgical complications early.

Choice D rationale

Keeping the residual limb uncovered might be necessary in some cases, but initial assessment and monitoring are more important immediately after surgery. .

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Correct Answer is A

Explanation

Choice A rationale

Having the patient lift their back and buttocks using a trapeze allows for proper assessment of pressure areas and skin care. This technique reduces the risk of further injury or discomfort and provides better access for the nurse to assess the skin condition.

Choice B rationale

Asking the patient to turn to the side independently may not be feasible for a patient with a pelvic fracture. This method can cause pain and risk further injury, making it an unsuitable choice for assessing pressure areas.

Choice C rationale

Rolling the patient over to the side by pushing on the patient's hip is not recommended as it can exacerbate the injury and cause pain. This method is not appropriate for patients with pelvic fractures.

Choice D rationale

Deferring back assessment until the patient is ambulatory is not a safe practice. Pressure areas should be regularly assessed to prevent skin breakdown and complications, even if the patient is not yet ambulatory.

A. Increase the client's fluid intake to prevent dehydration. B. Administer prescribed diuretics to reduce fluid overload. C. Apply warm compresses to the lower extremities to reduce edema. D. Encourage the client to ambulate to improve circulation.

Correct Answer is B

Explanation

Choice A rationale

Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.

Choice B rationale

Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.

Choice C rationale

Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.

Choice D rationale

Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .

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A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting.When the patient arrives on the orthopedic unit after surgery, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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