The client has returned from surgery following a below the knee amputation (BKA). The residual limb is covered with a compression dressing. Immediately upon return from surgery, the dressing is dry. Thirty minutes later, a small amount of bloody drainage is noted on the dressing. What should be the nurse's priority action at this time?

Change the dressing

Notify the physician

Lower the head of the bed

Mark the area of drainage, time and date

Answer and Explanation

The Correct Answer is D

A.   While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B.   While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C.   Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D.   Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. While rapid weight gain is a concern, it's important to consider the underlying cause. If the weight gain is medication-related (as in option B), it's a significant risk factor. However, if it's due to other factors like increased appetite or decreased activity, it might not be as directly linked to diabetes risk.
B. Many antipsychotic medications, including aripiprazole, have been linked to metabolic side effects like weight gain, increased blood glucose levels, and dyslipidemia. These metabolic changes can increase the risk of developing type 2 diabetes.
C. A sedentary lifestyle is a well-known risk factor for type 2 diabetes. Reduced physical activity can lead to insulin resistance, a condition where the body's cells become less responsive to insulin.
D. A diet rich in vegetables and lean protein is generally healthy and can help prevent chronic diseases. This option does not directly increase the risk of type 2 diabetes.
E. A random blood glucose level above 200 mg/dL is indicative of diabetes. This is a clear marker of impaired glucose metabolism and a significant risk factor for type 2 diabetes.

A. Complaints of muscle cramps with exercise B. Complaints of burning pain during the night C. Pedal pulses are +1 bilaterally D. Tissue that is blackened on the great toe

Correct Answer is B

Explanation

A. While claudication (muscle cramps with exercise) is common in earlier stages of PAD, it typically occurs in stage II. In stage III, pain often occurs at rest rather than with exertion.
B. In stage III PAD, patients often report rest pain, which can manifest as burning pain in the legs or feet, particularly at night when lying down. This is a hallmark symptom of advanced PAD due to inadequate blood flow.
C. While diminished pulses (like +1) can be found in PAD, this finding alone is not specific to stage III. In advanced stages, pulses may be even weaker or absent.
D. Blackened tissue (necrosis or gangrene) indicates a more severe stage (stage IV) of PAD, where there is critical limb ischemia and tissue death due to a lack of blood flow. Stage III may involve severe pain but usually does not have necrosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What factors in the history of a client with schizoaffective disorders puts the client at higher risk for type 2 diabetes? (SELECT ALL THAT APPLY)

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

Explanation

The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Correct Answer is B

Explanation

A client's insulin dosage is 16 units of regular insulin in the morning. The client should be taught to expect the insulin peak within:

The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:

A nurse is aware that which of the following social inequities are correlated with increased diabetes prevalence & more severe complications of diabetes? (SELECT ALL THAT APPLY)

The client is receiving a trimethoprim-sulfamethoxazole. What information should the nurse include in the teaching about this medication?

Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to: