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 B

Explanation

A. While staying hydrated is essential, especially during illness, limiting intake to non-caloric liquids could lead to inadequate caloric intake and worsen the client’s condition. Instead, the client should maintain a balanced intake of fluids and carbohydrates as tolerated.
B. This is a reasonable approach. Monitoring blood glucose levels regularly allows the client to assess how their body is responding to the illness and any adjustments in insulin. If the levels continue to rise, it is important for the client to seek medical attention to prevent complications like diabetic ketoacidosis (DKA).
C. While it is important to manage carbohydrate intake, completely decreasing carbohydrate intake can lead to inadequate caloric consumption, which is especially risky during an illness. The body needs energy, and people with diabetes must balance carbohydrate intake with insulin administration to avoid complications.
D. Holding insulin can lead to dangerously high blood glucose levels. Clients with Type 1 diabetes require insulin regardless of illness, and it’s crucial to adjust the insulin regimen based on current blood glucose levels and carbohydrate intake.

A. Supine with the right leg extended and flat B. High-Fowler's with the right leg extended C. Semi-Fowler's with the right leg on two pillows D. Supine with the right leg flexed at a 45-degree angle

Correct Answer is C

Explanation

A. This position can increase pressure on the surgical site and hinder blood flow.
B. This position can also increase pressure on the surgical site and may be uncomfortable for the client.
C. This position promotes venous return, reduces swelling, and minimizes pressure on the surgical site.
D. This position can increase pressure on the surgical site and may hinder blood flow.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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