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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Flushed, hot skin is not directly related to the client's CBC results. This symptom can indicate various conditions, such as fever, inflammation, or an allergic reaction, but it does not specifically correlate with the lab findings provided. The client's WBC count, hemoglobin, hematocrit, and basophils are within normal ranges, and the most significant abnormality is the low platelet count.
Choice B reason: Hives, or urticaria, are typically associated with allergic reactions and not directly related to the client's CBC results. While a low platelet count can sometimes be associated with immune-mediated conditions, hives are not a primary symptom of thrombocytopenia (low platelet count). The main concern with a low platelet count is the increased risk of bleeding and bruising.
Choice C reason: Inelastic turgor is a sign of dehydration or poor skin elasticity, often seen in conditions such as severe dehydration or malnutrition. The client's CBC results do not indicate dehydration or issues with skin turgor. The hemoglobin and hematocrit levels are within normal ranges, suggesting that the client's overall fluid status is likely stable.
Choice D reason: Bruising is the most relevant finding to assess for in a client with a low platelet count (thrombocytopenia). Platelets play a crucial role in blood clotting, and a low platelet count increases the risk of bleeding and easy bruising. The client's platelet count of 98,000/mm³ (98 x 10⁹/L) is below the normal range, which predisposes them to bruising and potential bleeding complications. It is important for the practical nurse to assess for signs of bruising and bleeding and to monitor the client closely for any further complications.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: Checking mucous membranes can provide information about the client's hydration status. Dry mucous membranes can be a sign of dehydration, which may contribute to decreased urine output. This assessment is important to determine whether the client has adequate fluid balance.
Choice B reason: Ensuring that the catheter tubing is straight is essential to confirm that there are no kinks or obstructions that could be causing the reduced urine flow. Any obstruction in the catheter tubing could lead to a sudden decrease in urine output, and this check helps ensure patency.
Choice C reason: Auscultating lung sounds is crucial to assess for fluid overload or pulmonary complications, which can be associated with renal transplant patients. Abnormal lung sounds could indicate issues that may indirectly affect urine output and overall kidney function.
Choice D reason: Determining the dryness of bed linens helps assess whether the client might have experienced a leakage of urine outside the catheter system. If the bed linens are wet, it could indicate an issue with the catheter or bladder function that needs to be addressed.
Choice E reason: Irrigating the catheter to assess patency is a direct method to determine whether there is any blockage or obstruction in the catheter. This procedure helps ensure that the catheter is functioning correctly and allows for appropriate urine drainage.
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