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 []

Explanation

Deep vein thrombosis (DVT): The client presents with classic signs of DVT, including calf tenderness, unilateral edema and redness, increased calf circumference, low-grade fever, and a history of immobility following surgery—all of which increase thrombotic risk. A STAT Doppler and D-dimer were appropriately ordered, both of which help confirm or rule out DVT.
Begin anticoagulation therapy: Anticoagulants like enoxaparin reduce clot propagation and the risk of pulmonary embolism, the most serious complication of DVT. This is a standard first-line treatment following a positive diagnosis or high clinical suspicion.
Early ambulation: After stabilization and with provider clearance, early ambulation is encouraged to enhance venous return and prevent further thrombus formation. It must be done cautiously to avoid dislodging a clot if DVT is still untreated or unstable.
Massage the calf area: This is contraindicated, as it may dislodge a clot and cause embolization to the lungs. It is strictly avoided in suspected or confirmed cases of DVT.
Prep for return to surgery / Culture hip wound: These are not relevant to the current clinical concern. The surgical wound has minimal drainage, with no signs of infection or dehiscence.
Development of pulmonary embolus: Clients with DVT are at high risk for PE. Monitoring for chest pain, shortness of breath, decreased oxygen saturation, and respiratory distress is essential for early detection and intervention.
Laboratory values: Ongoing assessment of coagulation labs (PT, aPTT, platelet count) and renal function is critical to safely manage anticoagulation and ensure therapeutic response.
Wound drainage / Nutritional intake / I&O: These are important for general postoperative care but are not specific to monitoring progress related to DVT or anticoagulation therapy.

A. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. B. Continue using the ointment for a full week, even after the symptoms disappear. C. Antibiotics take two weeks to become effective against infections such as athlete's foot. D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.

Correct Answer is D

Explanation

A. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration: While overuse of ointments may cause skin breakdown, this does not address the root issue. Athlete's foot is a fungal infection, and triple antibiotic ointments are ineffective against fungi regardless of the quantity applied.

B. Continue using the ointment for a full week, even after the symptoms disappear: Triple antibiotic ointment targets bacterial infections, not fungal ones like athlete's foot (tinea pedis). Continuing an ineffective treatment delays proper care and may worsen the condition due to persistent fungal growth.

C. Antibiotics take two weeks to become effective against infections such as athlete's foot: This is incorrect, as antibiotics do not treat fungal infections. Athlete's foot requires antifungal therapy, either topical or systemic depending on severity, and proper hygiene to promote resolution.

D. Stop using the ointment and encourage complete drying of feet and wearing clean socks: Fungi thrive in moist, warm environments. Discontinuing the inappropriate antibiotic ointment, promoting foot hygiene, and keeping the feet dry with clean, breathable socks directly addresses the fungal nature of the condition and supports healing.

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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 []

Explanation

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?

Correct Answer is D

Explanation

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

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Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has dropdown evidenced by dropdown and dropdown.

The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum?

Exhibits For each action, click to indicate whether the actions are indicated or contraindicated for postoperative amputation. Each column must have at least one response option selected.

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.