The nurse is caring for a client who has just returned to the nursing unit following a below-the-knee amputation (BKA) of the right leg.
How should this client be positioned?
Trendelenburg with the stump supported on three pillows.
Side lying with amputated leg flexed.
Prone for 24 hours.
Supine with the stump flat on the bed.
The Correct Answer is D
Choice A rationale
The Trendelenburg position, with the stump supported on three pillows, is not typically recommended following a below-the-knee amputation. This position could increase the risk of contractures.
Choice B rationale
Side lying with the amputated leg flexed is not typically recommended following a below-the- knee amputation. This position could increase the risk of contractures.
Choice C rationale
Lying prone for 24 hours is not typically recommended following a below-the-knee amputation. While some prone positioning may be beneficial to prevent hip flexion contractures, it should not be the only position used.
Choice D rationale
The supine position, with the stump flat on the bed, is often recommended following a below- the-knee amputation. This position helps to prevent contractures and promotes healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
Choice B rationale
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.
However, the risk is not as high as in patients who have undergone major open abdominal surgery.
Choice C rationale
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
Choice D rationale
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
Correct Answer is C
Explanation
Choice A rationale
Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.
Choice B rationale
Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.
Choice C rationale
This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.
Choice D rationale
Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.
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