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
Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.
Choice B rationale
Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.
Choice C rationale
Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.
Choice D rationale
Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.
Correct Answer is C
Explanation
Choice A rationale
Limiting intake to non-caloric containing liquids until the glucose is within normal limits is not the best advice for a patient with Type 1 diabetes reporting a blood glucose level of 210 mg/dL and symptoms of a sore throat, cough, and fever. While it’s important to stay hydrated, especially when sick, it’s also crucial to maintain a balanced diet to provide the body with necessary nutrients for recovery.
Choice B rationale
Decreasing intake of carbohydrates until blood glucose level is less than 100 mg/dL is not recommended. Carbohydrates are a primary source of energy, and reducing their intake could lead to low blood sugar or hypoglycemia, which can be dangerous.
Choice C rationale
Monitoring blood glucose levels every 4 hours and notifying the doctor if it continues to rise is the best advice. When a patient with diabetes is sick, their blood glucose levels can rise due to the stress the body is under. Regular monitoring allows for timely adjustments in insulin dosage and helps prevent diabetic ketoacidosis, a serious complication.
Choice D rationale
Administering only the morning prescribed dose of insulin is not advisable. Insulin requirements can increase when a person with diabetes is sick. Therefore, sticking to the regular insulin regimen without adjustments could lead to high blood sugar or hyperglycemia.
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