Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease. Each row must have one option response selected.

Asks questions about self care

Executes pull ups on trapeze bar

Requests nurse to perform wound care

Turns side to side

Avoids looking at residual limb

Inquires about blood pressure

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Positive:

Asks questions about self-care
Executes pull-ups on trapeze bar
Turns side to side
Inquires about blood pressure

Negative:

Requests nurse to perform wound care
Avoids looking at residual limb

Rationale:

Asks questions about self-care: Asking questions reflects the client’s engagement in learning about their recovery and adapting to life after amputation. It supports early involvement in rehabilitation, self-management of the residual limb, and planning for long-term independence.
Executes pull-ups on trapeze bar: Using a trapeze bar demonstrates initiative in strengthening upper body muscles, which are vital for mobility and transfers post-amputation. This activity promotes functional independence and supports participation in physical therapy.
Requests nurse to perform wound care: Relying on the nurse for routine wound care may delay the development of self-care skills. Encouraging the client to participate in their own wound care fosters autonomy and reduces dependence on healthcare staff.
Turns side to side: Repositioning helps maintain skin integrity, promotes circulation, and prevents pressure injuries, particularly important for clients with vascular disease. This action shows awareness of good postoperative care habits.
Avoids looking at residual limb: Avoiding the residual limb may suggest emotional distress or difficulty accepting body image changes. This behavior can interfere with psychological recovery and delay participation in rehabilitation activities.
Inquires about blood pressure: Asking about blood pressure demonstrates awareness of the importance of managing chronic conditions like hypertension. Monitoring blood pressure is crucial to preventing further vascular damage and supporting long-term health.

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Correct Answer is ["A","B","C","E","F"]

Explanation

Right leg: Skin cool to touch with edema along the incision: These signs suggest impaired perfusion and possible early infection or inflammation. Although there's no redness, edema and coolness warrant continued monitoring for progression or signs of infection.
Right leg: 100 mL of wound drainage present: This is a moderately high amount of drainage for postoperative day 3. While not yet excessive, the color, consistency, and ongoing amount must be monitored closely for signs of infection or wound dehiscence.
Left leg: Loss of hair on lower leg, dry/scaly/cool skin: These are classic signs of chronic peripheral arterial disease (PAD), reflecting poor circulation. This limb is also at risk for ischemia and future complications, especially with the client's history of PVD and a recent amputation on the opposite leg.
Left leg: Thickened toenails: This indicates chronic poor circulation and possibly fungal infection or tissue ischemia. It reflects long-standing vascular compromise and should be documented and evaluated by vascular or podiatry teams.
Left leg: Capillary refill greater than 4 seconds: This is a clear indicator of impaired peripheral perfusion. Normal refill is under 2 seconds; delayed refill confirms compromised blood flow and requires further vascular evaluation or intervention.

A. Applies prescribed lotions to the radiation site. B. Washes the radiation site with antibacterial soap and water. C. Dries the area with patting motions after taking a shower. D. Wears clothing to cover the radiation site.

Correct Answer is B

Explanation

A. Applies prescribed lotions to the radiation site: The use of lotions specifically prescribed by the healthcare team is encouraged, as these formulations are designed to soothe irritated skin without interfering with the effectiveness of radiation therapy or exacerbating skin sensitivity.

B. Washes the radiation site with antibacterial soap and water: Antibacterial soaps often contain harsh chemicals that can irritate sensitive skin, especially when the skin is already compromised by radiation exposure. Mild, unscented soap and lukewarm water are recommended to prevent further skin breakdown and discomfort during the treatment period.

C. Dries the area with patting motions after taking a shower: Gently patting the skin dry, rather than rubbing, helps prevent mechanical irritation to the fragile tissue at the radiation site. This technique supports skin integrity and minimizes the risk of skin damage during hygiene routines.

D. Wears clothing to cover the radiation site: Covering the site with soft, breathable clothing provides protection from environmental elements such as sun exposure and friction, which can aggravate radiation dermatitis. Clothing should be non-restrictive to avoid rubbing or pressure on the affected area.

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Exhibits For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease. Each row must have one option response selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E","F"]

Explanation

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Correct Answer is B

Explanation

An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply

The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is most important for the nurse to implement?

Exhibits Click to indicate if the listed symptoms are consistent with angina, myocardial infarction, or both. Each column must have at least one response option selected.

Exhibits Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client.

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide?

Exhibits

For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease. Each row must have one option response selected.