Which nursing action(s) should the nurse include in the post-op plan of care for a client recovering from a below-the-knee amputation?
Administering pain medication as needed.
Encouraging the client to bear weight on the affected limb immediately after surgery.
Restricting the client's mobility and keeping the client on bed rest.
Applying a tight compression bandage on the residual limb.
The Correct Answer is A
Choice A reason:
Post-operative pain management is a critical aspect of care for a client recovering from a below-the-knee amputation. Administering pain medication as needed helps to manage pain effectively, which is essential for the client's comfort and recovery. Pain control is also important to facilitate participation in rehabilitation activities.
Choice B reason:
It is not advisable to encourage the client to bear weight on the affected limb immediately after surgery. The residual limb needs time to heal, and premature weight-bearing can lead to complications such as delayed healing or wound dehiscence.
Choice C reason:
While it is important to prevent complications such as deep vein thrombosis, complete restriction of mobility and keeping the client on bed rest is not recommended. Early mobilization, as part of a rehabilitation program, is essential for improving circulation, preventing muscle atrophy, and promoting overall recovery.
Choice D reason:
Applying a tight compression bandage on the residual limb is a common practice in the post-operative care of clients with amputations. The compression bandage helps to control swelling, shape the limb for a prosthesis, and prevent fluid accumulation. However, the bandage must be applied correctly to avoid impairing circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason:
Packaged meats, including salami and bacon, are typically high in sodium, which can contribute to increased blood pressure. The American Heart Association recommends that individuals with hypertension limit their sodium intake to no more than 2,300 milligrams per day, with an ideal limit of no more than 1,500 milligrams for most adults². Since packaged meats are often cured with salt, they can significantly contribute to the daily sodium intake, potentially exacerbating hypertension.
Choice B reason:
Grapefruit juice can interact with certain antihypertensive medications, potentially leading to higher levels of the medication in the bloodstream and an increased risk of side effects¹. This interaction occurs because grapefruit juice can inhibit the action of an enzyme that metabolizes medication, leading to an unintended increase in medication levels.
Choice C reason:
Canned soups are often high in sodium, which can contribute to increased blood pressure. Even low-sodium varieties can still contain significant amounts of sodium. It's important for individuals with hypertension to read labels carefully and choose options with the lowest sodium content possible².
Choice D reason:
Fresh fruits are generally recommended for individuals with hypertension. They are rich in potassium, which can help lower blood pressure by balancing out the negative effects of sodium and easing tension in the blood vessel walls¹. Fresh fruits should not be avoided unless there is a specific reason related to another health condition or medication interaction.
Choice E reason:
Fresh shellfish, like fresh fruits, are typically safe for individuals with hypertension to consume. They provide essential nutrients without the added sodium that is found in processed foods. However, it's important to consume them in moderation and to prepare them without adding excessive salt or high-sodium sauces.
Correct Answer is B
Explanation
Choice a reason:
Placing the client on a 35% Venturi mask would provide a controlled amount of oxygen which is beneficial for clients with chronic obstructive pulmonary disease (COPD) who may retain carbon dioxide. However, this intervention is not directly related to the management of a non-productive cough and difficulty expectorating secretions.
Choice b reason:
Encouraging the client to increase liquid intake throughout the day can help thin the bronchial secretions, making them easier to expectorate. Adequate hydration is essential in the management of chronic bronchitis to help clear mucus from the airways.
Choice c reason:
Administering dextromethorphan, a cough suppressant, may be used to control a non-productive cough. However, it would not assist with the expectoration of secretions and could potentially inhibit the cough reflex needed to clear the airways.
Choice d reason:
Encouraging pursed-lip breathing can help improve ventilation and oxygenation by promoting more effective exhalation. This technique can be beneficial for clients with COPD but does not directly address the issue of expectorating secretions.
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