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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing blood pressure with a sphygmomanometer is unrelated to Chvostek's sign, which specifically evaluates neuromuscular excitability.
B. Chvostek's sign is assessed by tapping the facial nerve near the cheekbone. A positive response, such as twitching of the facial muscles, indicates hypocalcemia or neuromuscular irritability.
C. Assessing heart rate with a stethoscope does not involve evaluating neuromuscular function or calcium levels.
D. Monitoring respiratory rate with a pulse oximeter is unrelated to Chvostek's sign and does not assess neuromuscular excitability.
Correct Answer is D
Explanation
A. A client with heart failure and crackles in the lungs is more likely to have fluid volume excess rather than deficit.
B. A client with renal failure and pitting edema is typically at risk for fluid retention and overload, not deficit.
C. Being NPO for 4 hours is unlikely to cause significant fluid volume deficit, as this is a short period without oral intake.
D. A client with Crohn's disease experiencing diarrhea is losing significant fluids and electrolytes, placing them at high risk for fluid volume deficit. Diarrhea is a common cause of dehydration and requires close monitoring.
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