The practical nurse (PN) is caring for a client with type 1 diabetes mellitus. Which intervention should the PN implement immediately after a below-the-knee (BKA) amputation due to gangrene?

Position the client supine and flat to prevent phantom pain.

Turn the client prone every 2 hours to prevent hip flexion contractures.

Elevate the residual limb on pillows to prevent bleeding and swelling.

Position the residual limb below the heart to promote healing for prosthetic fitting.

Answer and Explanation

The Correct Answer is C

Choice A reason: Positioning the client supine and flat is not specifically aimed at preventing phantom pain. Phantom pain is a common issue after amputations, and its management typically involves medications, therapies, and psychological support rather than positioning. Keeping the client supine and flat may not address the immediate concerns of bleeding and swelling, which are critical in the initial postoperative period.
Choice B reason: Turning the client prone every 2 hours to prevent hip flexion contractures is an important intervention to prevent contractures after a below-the-knee amputation. However, this is not the immediate priority immediately following surgery. The primary concern in the immediate postoperative period is to manage bleeding, swelling, and ensuring proper healing of the residual limb.
Choice C reason: Elevating the residual limb on pillows to prevent bleeding and swelling is the most crucial intervention immediately after a below-the-knee amputation. Elevation helps reduce edema, promote venous return, and minimize the risk of postoperative bleeding. Proper elevation also supports the healing process of the surgical site. This intervention addresses the immediate needs of the client and helps prevent complications in the critical early stages after surgery.
Choice D reason: Positioning the residual limb below the heart to promote healing for prosthetic fitting is not recommended in the immediate postoperative period. Keeping the limb elevated is more beneficial to reduce swelling and manage bleeding. The focus in the immediate phase is to ensure proper healing and prevent complications, with considerations for prosthetic fitting coming later in the rehabilitation process.

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Correct Answer is C

Explanation

Choice A reason: Returning for a urine culture and imaging is an important part of follow-up care for a client with pyelonephritis. These tests can help ensure that the infection has been completely resolved and that there are no underlying structural abnormalities contributing to the condition. However, while follow-up appointments are crucial, the immediate priority for discharge instructions is to emphasize the importance of adhering to the prescribed medication regimen to ensure the effectiveness of the treatment.
Choice B reason: Using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain can help manage discomfort associated with pyelonephritis. However, pain management is secondary to ensuring that the infection is effectively treated. While it is important to address the client's pain, reinforcing the need to follow the prescribed medication regimen takes precedence to ensure that the infection is adequately managed and prevented from worsening or recurring.
Choice C reason: Adhering strictly to the medication regimen is the most important instruction for the client. Ensuring that the client takes the full course of prescribed antibiotics is critical to effectively treating the pyelonephritis and preventing the development of antibiotic resistance or recurrent infections. Reinforcing the importance of completing the antibiotic course as directed helps ensure that the infection is fully eradicated and reduces the risk of complications.
Choice D reason: Ensuring effective perineal hygiene is important for preventing urinary tract infections (UTIs) and maintaining overall urinary health. While it is a relevant aspect of care, it is not the most critical instruction for the client at the point of discharge. The primary focus should be on the adherence to the medication regimen to treat the current infection and prevent further complications. Perineal hygiene practices can be reinforced as part of overall health education but are not the immediate priority compared to medication adherence.

A. Suction equipment. B. Crash cart. C. Non-rebreather mask. D. Nasogastric tube. E. Wire cutters.

Correct Answer is ["A","E"]

Explanation

Choice A reason: Suction equipment is essential for a client who has undergone fixation of a mandible fracture. Due to the nature of the surgery and the presence of wiring, the client may have difficulty managing oral secretions. Suction equipment ensures that any secretions can be promptly and effectively removed, preventing aspiration and maintaining a clear airway. This equipment is vital for managing the client's immediate postoperative needs and ensuring their safety.
Choice B reason: A crash cart, while critical in emergency situations, is not specifically required to be present in the client's room following mandible fracture fixation. Crash carts are typically available on the unit and can be quickly brought to the room if needed. The practical nurse should be familiar with the location of the crash cart and how to access it, but it does not need to be permanently stationed in the client's room.
Choice C reason: A non-rebreather mask is used to deliver high concentrations of oxygen to clients experiencing severe respiratory distress or hypoxemia. While it is an important piece of equipment for respiratory emergencies, it is not specifically necessary to have in the room of a client with a mandible fracture fixation. The priority is to have suction equipment and wire cutters immediately available, while other oxygen delivery devices can be accessed as needed.
Choice D reason: A nasogastric tube is used for decompression of the stomach or for feeding clients who are unable to take oral nutrition. It is not specifically required for a client with a mandible fracture fixation unless there are additional complications or indications for its use. The practical nurse should focus on equipment directly related to managing the fixation and maintaining the client's airway.
Choice E reason: Wire cutters are a critical item to have in the room of a client with a mandible fracture fixation. In the event of an emergency, such as vomiting or respiratory distress, the wires securing the mandible may need to be quickly cut to ensure the client's airway is not compromised. Having wire cutters immediately available ensures that the practical nurse can respond swiftly and effectively to any urgent situations, maintaining the client's safety and airway patency.

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The practical nurse (PN) is caring for a client with type 1 diabetes mellitus. Which intervention should the PN implement immediately after a below-the-knee (BKA) amputation due to gangrene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client with pyelonephritis who is admitted for parenteral anti-infective therapy. Prior to discharge home with an oral medication regimen, which instruction is most important for the practical nurse (PN) to reinforce with the client?

Correct Answer is C

Explanation

The practical nurse (PN) is assigned to care for a client who underwent fixation of a mandible fracture. Upon entering the client's room, the PN should confirm the presence of which item(s) in the client's room? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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