Nokea
The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation?
- A. Clean the wound with hydrogen peroxide three times a day
- B. Have the client lie prone several times a day
- C. Ask the client to flex and extend the toes on the remaining leg
- D. Encourage the client to completely empty his/her bladder
Correct Answer: B
Rationale: Lying prone prevents hip flexion contractures, the most common complication post-amputation.
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Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate discontinuation and physician notification, as it can precede serious complications like bone marrow suppression. Other symptoms are less urgent.
The nurse is caring for a client prior to surgery to repair a broken right hip. Which nursing care measure is essential?
- A. Get the client out of bed twice a day to maintain mobility
- B. Use pillows to maintain the right hip in a state of abduction
- C. Elevate the foot of the bed to 25 degrees
- D. Feed the client to conserve her energy
Correct Answer: B
Rationale: Maintaining abduction with pillows prevents dislocation and aligns the hip pre-surgery.
Which of the following evening snacks would the nurse encourage for the client with immobility due to the fractured hip?
- A. An orange
- B. Rice cakes
- C. Peanut butter and celery
- D. Potato chips
Correct Answer: C
Rationale: Peanut butter and celery provide protein and healthy fats, supporting tissue repair and nutrition during immobility. Oranges offer vitamin C but less protein, while rice cakes and potato chips lack substantial nutritional value.
The nurse is caring for a client with a newly applied plaster cast. How should the nurse touch and move the wet cast?
- A. Use the palms of the hands
- B. Use the fingertips only
- C. Use a towel sling
- D. Touch the cast only on the petals at the edges
Correct Answer: A
Rationale: Using the palms prevents indentations in a wet cast, which could cause skin irritation. Fingertips create indentations, a towel sling is inappropriate, and petaling occurs after drying.
The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?
- A. Fish
- B. Milk
- C. Eggs
- D. Liver
Correct Answer: D
Rationale: Liver is high in purines, which exacerbate gout.