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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

While holding the warfarin and notifying the laboratory could be appropriate actions in some situations, they would not address the immediate concern of the large, new ecchymotic areas on the client’s extremities.

Choice B rationale

Administering the daily dose of warfarin and notifying the healthcare provider for a dose adjustment the next day could potentially exacerbate the bleeding risk, given the presence of the large, new ecchymotic areas.

Choice C rationale

Large, new ecchymotic areas are not expected side effects of warfarin. They could indicate a serious problem such as excessive anticoagulation.

Choice D rationale

The presence of large, new ecchymotic areas could indicate excessive anticoagulation, which is a serious complication of warfarin therapy. Therefore, holding the warfarin and notifying the healthcare provider of the assessment findings would be the most appropriate initial action.

A. Assess for Red Man Syndrome B. Assess the client’s hearing C. Obtain an arterial blood gas (ABG) D. Infuse the drug over 1-2 hours E. Obtain an ordered trough level prior to next scheduled dose

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.

Choice B rationale

Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.

Choice C rationale

Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.

Choice D rationale

Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.

Choice E rationale

Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a client’s warfarin sodium 5 mg PO at 1900. Upon entering the client’s room, the nurse finds several large, new ecchymotic areas on the client’s extremities. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days. What nursing actions are appropriate when administering this medication? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

A client is receiving heparin sodium 1000 units per hour via an infusion and warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg. The nurse educates the client that heparin and warfarin are prescribed together because:

The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

A client has recently been diagnosed with Type 2 diabetes. What should be the nurse’s initial step when developing an educational plan?

To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

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

The nurse receives an order to administer cefazolin to a client diagnosed with a urinary tract infection. The nurse withholds the medication and notifies the health care provider because the client:

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?