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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Volume to administer (mL)=( Desired dose (mcg)/Available concentration (mcg/mL) 100 mcg is in 2 mL, so the concentration is:
100 mcg/2 Ml =50 mcg/mL
Volume to administer =25 mcg/ 50 mcg/mL=0.5mL
So, the nurse will administer 0.5 mL of fentanyl for the correct dose.
Correct Answer is B
Explanation
A. While exercise is an important aspect of diabetes management, particularly for blood glucose control and overall health, it is not the immediate priority for a newly diagnosed client. Understanding how to manage blood glucose levels is more critical initially.
B. For a client who is newly diagnosed with insulin-dependent diabetes, learning how to administer insulin is essential. This includes understanding how to prepare, inject, and store insulin, as well as recognizing the signs of hypoglycemia and hyperglycemia. Proper insulin administration is crucial for managing blood glucose levels and preventing complications.
C. Understanding dietary management is important in diabetes care, as it plays a significant role in blood sugar control. However, without knowing how to administer insulin, a client may struggle to manage their blood glucose levels effectively, making insulin administration a higher priority initially.
D. While monitoring urine for ketones is important, particularly in cases of potential diabetic ketoacidosis (DKA), this is not the first priority for a newly diagnosed client. The focus should be on fundamental skills and knowledge for managing diabetes, such as insulin administration.
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