Nokea
A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period?
- A. Neuroma
- B. Hematoma
- C. Chronic osteomyelitis
- D. Unexplainable burning pain (causalgia)
Correct Answer: B
Rationale: Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period. Sleeplessness, nausea, and vomiting may occur but are adverse reactions, not complications. Chronic osteomyelitis and causalgia are potential complications that are likely to arise in the late postoperative period. A neuroma occurs when the cut ends of the nerves become entangled in the healing scar. This would occur later in the postoperative course.
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A patient is scheduled for hip replacement surgery in a month. Which statement made by the client demonstrates understanding for the preoperative instructions?
- A. I will stop taking my antihypertensive medications prior to my surgery.
- B. I will stop taking my aspirin prior to my surgery.
- C. I will have heat packs applied to my hip immediately after surgery.
- D. I will be able to walk independently when I wake up from surgery.
Correct Answer: B
Rationale: If a client is scheduled for joint replacement or other surgery, the client should be instructed to withhold aspirin prior to the surgery as per physician's instructions. The client should not be instructed to withhold antihypertensive medications to avoid a rebound hypertension. Cold packs, not heat packs, will be applied to reduce pain and edema after surgery. The client will require physical therapy after surgery and will not be able to walk until day 2 with assistance.
The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse: 'If my leg is really gone, then why am I having such bad pain?' What is an appropriate response by the nurse?
- A. You are only imagining that you are having pain.
- B. It is called phantom pain and may come and go.
- C. You will continue to have this pain, and you will have to learn to ignore it.
- D. This is called false pain and is a brain dysfunction.
Correct Answer: B
Rationale: Phantom pain is pain or other discomfort, such as burning, tingling, throbbing, or itching. Pain felt from the phantom limb can be an extremely serious problem in relation to the client's emotional status and ability to use prosthesis. The other responses are nontherapeutic.
The nurse is caring for a client who had an amputation of the left leg above the knee. What position can the nurse place the client in several times per day to promote stump extension and prevent contractures?
- A. Supine
- B. Left lateral
- C. Prone
- D. Right lateral
Correct Answer: C
Rationale: Place the client with leg amputation in the prone position several times a day. This position promotes stump extension and prevents contractures. The other positions do neither of these things.
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed?
- A. The leg will look as it did prior to the cast being applied.
- B. The leg will look moist and will have small bumps that will go away in a few days.
- C. The skin may be covered with a yellowish crust that will shed in a few days.
- D. The leg strength is enforced by the wearing of the cast.
Correct Answer: C
Rationale: Once the cast is off, the skin appears mottled and may be covered with a yellowish crust composed of accumulated body oil and dead skin. The client usually sheds this residue in a few days. The leg will not look as it did prior to the cast but will regain the same shape and status as the other leg. There should be no bumps underneath the cast. The leg may be weak and stiff for some time after the cast is removed, not stronger.
The nurse is caring for a patient with a fractured right femur who is not a candidate to repair the femur immediately. What intervention should the nurse anticipate the physician will order to relieve muscle spasm and pain until surgery is performed?
- A. Skeletal traction
- B. Skin traction
- C. Open reduction
- D. External fixator
Correct Answer: B
Rationale: If surgery for a fracture cannot be performed right away, Buck's traction or other skin traction may be applied to relieve muscle spasm and pain until surgery is performed. The other distractors all require surgical intervention.