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
Wearing closed-toe shoes when walking can help protect the feet from injuries. However, it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice B rationale
Soaking feet daily to remove pathogens can help maintain hygiene, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice C rationale
Examining your feet daily is a crucial intervention for patients with severe peripheral neuropathy. Due to the numbness and reduced sensation, patients might not notice injuries or changes in their feet. Regular self-examination can help detect any abnormalities early, preventing further complications.
Choice D rationale
Using lotion on all areas of the feet for moisture can help prevent dryness and cracking of the skin, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Correct Answer is A
Explanation
Choice A rationale
The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.
Choice B rationale
While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.
Choice C rationale
Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.
Choice D rationale
Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.