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Later the client says, 'I know my arm isn't there, but I feel it throbbing.' Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is a common sensation of pain in the amputated limb due to nerve endings firing, accurately describing the client's experience. The other options misattribute the cause.
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The nurse gently elevates the client's newly casted arm on a pillow and explains that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this action?
- A. It helps a damp cast to dry more evenly.
- B. It reduces the amount of pain medication needed.
- C. Venous return is enhanced, and edema is decreased.
- D. It is more comfortable than keeping the arm dependent.
Correct Answer: C
Rationale: Elevation enhances venous return and reduces edema, the primary reason for this action. It does not directly affect cast drying, pain medication needs, or comfort alone.
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Set the heating pad to the highest setting.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: A low setting prevents burns while providing therapeutic heat.
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately?
- A. Localized edema and discoloration occurring hours after the injury.
- B. Generalized weakness and increasing sensitivity to touch.
- C. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain.
- D. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.
Correct Answer: C
Rationale: Absent pulses and increasing pain suggest compartment syndrome or arterial occlusion, requiring urgent HCP notification. Edema is expected, weakness is nonspecific, and pain relief is positive.
Which is the best technique for the nurse to use when applying the elastic bandage to the client's lower extremity?
- A. Making figure-eight turns with the bandage
- B. Making spiral-reverse turns with the bandage
- C. Making recurrent turns with the bandage
- D. Making spica turns with the bandage
Correct Answer: A
Rationale: The figure-eight technique provides even compression and support around the ankle joint, stabilizing it while allowing some flexibility. Spiral-reverse turns are better for cylindrical limbs, recurrent turns are used for stumps, and spica turns are typically for larger joints like the hip or shoulder.
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first?
- A. Notify the client's surgeon immediately.
- B. Assess the client's blood pressure and pulse.
- C. Reinforce the dressing with additional dressing.
- D. Check the client's last hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: Reinforcing the dressing controls bleeding, the priority in hemorrhage. Notifying the surgeon, assessing vitals, and checking labs are secondary.