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Exhibits

Select the Word Choices to complete the sentence.

The client is at risk for

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

  • Contractures: Postoperative clients with lower limb amputations are at high risk for developing joint contractures, particularly of the hip and knee. This risk increases when the residual limb remains in a flexed position for extended periods. Orders for the client to lie flat and assume a prone position twice daily are intended to stretch the hip flexors and prevent contracture formation, which can hinder prosthetic fitting and long-term mobility.
  • Infection: Despite no current redness or open drainage, the presence of edema and a surgical incision left open to air puts the client at ongoing risk for infection. Edema can impair tissue perfusion and slow wound healing, creating an environment favorable for bacterial growth. Frequent wound checks and adherence to sterile dressing changes are essential in monitoring for early signs of infection such as redness, warmth, or increased drainage.
  • Pneumonia: Although pneumonia is a risk in postoperative patients with limited mobility and opioid use, this client demonstrates normal respiratory status with clear lungs and is using an incentive spirometer as ordered.
  • Deep vein thrombosis (DVT): The client is receiving prophylactic enoxaparin, which significantly reduces the risk of thrombus formation. Although still important to monitor, the presence of pharmacologic prevention places DVT lower in priority at this time.
  • Neuroma: Neuroma formation, resulting from disorganized nerve healing at the amputation site, typically develops later in recovery. It is not a pressing concern in the immediate postoperative phase compared to infection and contractures, which can develop rapidly if not addressed early.


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Related Questions

Correct Answer is A

Explanation

A. Increase intake of insoluble fiber: In diverticulosis, the presence of small outpouchings in the colon wall is often linked to low-fiber diets. Increasing insoluble fiber promotes regular bowel movements, reduces intraluminal pressure, and prevents stool from stagnating in diverticula, thereby decreasing the risk of inflammation or diverticulitis.

B. Eliminate caffeine and chocolate: These substances are more commonly associated with exacerbating symptoms of irritable bowel syndrome (IBS) or gastroesophageal reflux disease (GERD), not typically diverticulosis.

C. Decrease foods high in fat or trans fats: Although limiting unhealthy fats is good for overall health, it is not the primary dietary focus in managing diverticulosis. Fiber intake plays a much more direct role in supporting colon health and preventing complications in these clients.

D. Augment intake of dairy products: Dairy is not contraindicated in diverticulosis, but it is also not specifically beneficial unless addressing a separate nutritional need such as calcium deficiency. Increasing dairy does not impact colonic transit or diverticular disease directly.

Correct Answer is A

Explanation

A. Lower back pain and hypotension: These are hallmark signs of an acute hemolytic transfusion reaction, often due to ABO incompatibility. Hemolysis releases free hemoglobin, which can damage the kidneys, and hypotension can indicate systemic inflammatory response or impending shock. Immediate reporting is necessary to prevent rapid deterioration and initiate emergency interventions.

B. Acute rhinitis and nasal stuffiness: These symptoms may suggest a mild allergic reaction or environmental sensitivity, but they are not associated with the serious and potentially life-threatening effects of an ABO incompatibility reaction. They do not require urgent escalation in this context.

C. Arthritic joint changes and chronic pain: Chronic joint issues are unrelated to transfusion reactions and reflect long-standing musculoskeletal conditions. These findings may be important for overall care but are not urgent or connected to transfusion complications.

D. Delayed painful rash with urticaria: Urticaria can occur as part of a mild allergic reaction to a transfusion, typically managed with antihistamines. While it should be documented and monitored, it is not as emergent as symptoms indicating intravascular hemolysis, such as back pain and hypotension.

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