The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

Instruct the client how to perform biofeedback exercises

Place the client's residual limb in the dependent position

Explain to the client his left leg has been amputated

Medicate the client with narcotic analgesic immediately

Answer and Explanation

The Correct Answer is D

A.   While biofeedback can be a helpful technique for managing pain in the long term, it is not an immediate intervention for acute pain. The client is expressing urgent pain that requires prompt action, so this option does not address the immediate need.
B.   Placing the residual limb in a dependent position (below the level of the heart) can increase swelling and may worsen the pain. After surgery, the limb should typically be elevated to minimize swelling, especially in the early postoperative period.

C.   While it is important for clients to understand their situation, explaining the amputation does not provide immediate relief for acute pain. The client is likely already aware of the amputation and is in distress, so this option is not a priority at this moment.
D.   This is the most appropriate intervention. The client is experiencing significant pain, and administering a narcotic analgesic can provide immediate relief. Pain management is a priority in the postoperative setting, especially in the first few hours after surgery.

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Correct Answer is A

Explanation

This is the expected peak time for regular insulin. After administration, insulin will generally reach its maximum effectiveness in lowering blood glucose within this timeframe, making it crucial for the client to eat or take carbohydrates to prevent hypoglycemia.

A. omitted meals. B. a GI disturbance. C. not taking insulin regularly. D. an insulin overdosage.

Correct Answer is C

Explanation

A. While skipping meals can affect blood glucose levels, it is not a direct primary cause of DKA. In some cases, if a person with Type 1 diabetes skips a meal and does not adjust their insulin accordingly, it could lead to hyperglycemia. However, the absence of insulin is the critical factor in DKA.
B. Gastrointestinal disturbances, such as vomiting or diarrhea, can contribute to DKA by leading to dehydration and altering insulin absorption. However, they are not primary causes. The main concern is that they may cause the individual to skip insulin or not manage their diabetes effectively.
C. DKA is primarily caused by a lack of insulin, which leads to the body breaking down fat for energy instead of glucose. This process produces ketones, which can accumulate and lead to acidosis. For individuals with Type 1 diabetes, consistently taking insulin is crucial to prevent DKA.
D. An insulin overdose can lead to hypoglycemia, not DKA. When too much insulin is taken, it can cause blood glucose levels to drop too low, which is the opposite of what occurs in DKA.

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The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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