Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?
Withhold medication for phantom limb pain as it isn't real pain.
Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible.
Continue using the limb prosthesis even if skin appears irritated.
Have the client lay prone for 30 minutes, 3-4 times a day.
The Correct Answer is D
A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Advising the client to add citrus juices and bananas is inappropriate because these are high in potassium and would further increase the already elevated potassium level, potentially worsening hyperkalemia.
B. Obtaining a 12-lead ECG is the correct action. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac arrhythmias. An ECG can help identify hyperkalemia-related changes, such as peaked T waves, widened QRS complexes, or arrhythmias.
C. While obtaining a serum sodium level might provide additional information, it does not address the immediate risk posed by the elevated potassium level. The priority is assessing the cardiac effects of hyperkalemia.
D. Suggesting that the client use a salt substitute is incorrect, as many salt substitutes contain potassium chloride, which could worsen hyperkalemia.
Correct Answer is ["44"]
Explanation
Calculate the flow rate in mL/hour: 400 mL / 3 hours = 133.33 mL/hour (approximately)
Convert the flow rate to mL/minute: 133.33 mL/hour / 60 minutes/hour = 2.22 mL/minute (approximately)
Calculate the drops per minute: 2.22 mL/minute 20 gtt/mL = 44.4 gtt/minute
Round to the nearest whole number: 44 gtt/minute
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