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 ["A","B"]
Explanation
A. Limited access to fresh fruits and vegetables can contribute to poor dietary habits, which are linked to obesity and diabetes. Communities with food deserts often have higher rates of diabetes due to reduced access to nutritious food, leading to diets high in processed and unhealthy foods.
B. Living in disadvantaged communities is associated with increased diabetes prevalence and complications. Factors such as lower socioeconomic status, limited access to healthcare, poor health education, and environmental stressors can exacerbate health issues, including diabetes.
C. Having adequate health insurance is generally correlated with better health outcomes, including access to preventive care, regular monitoring, and treatment for diabetes. It does not contribute to increased prevalence or complications; rather, it mitigates them.
D. While certain viral infections have been studied for their potential role in triggering autoimmune diabetes (such as Type 1 diabetes), viral infections themselves are not a social inequity and do not directly correlate with increased diabetes prevalence in the same way that socioeconomic factors do.
E. Autoimmune disorders can be associated with Type 1 diabetes and some cases of Type 2 diabetes; however, this option does not reflect a social inequity. Instead, autoimmune disorders are more related to individual health conditions and genetics.
Correct Answer is B
Explanation
A. While monitoring is important, doing nothing to address the hypoglycemia is not safe. A blood glucose level of 50 mg/dL is low and requires immediate intervention to prevent more severe hypoglycemic symptoms or complications.
B. This is a suitable option for treating mild to moderate hypoglycemia. Orange juice is a quick source of carbohydrates and can effectively raise blood glucose levels. Four ounces typically provides enough sugar to help increase the client's blood glucose level before dinner is served.
C. While this option would also effectively raise blood glucose, it is more complicated than simply having the client drink orange juice. The sugar may take additional time to dissolve, and grape juice may not be readily available. In an acute situation, simplicity and speed are key.
D. While hard candy can raise blood glucose levels, it may take longer to dissolve and provide sufficient glucose quickly compared to liquid sources like orange juice or grape juice. Additionally, the amount of candy needed may not be clear, making this a less reliable option in an urgent situation.
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