Nokea
The client diagnosed with osteomyelitis of the left foot and ankle is being prepared for a below-the-knee amputation. Which intervention to improve the client’s functional ability is a priority after rehabilitation?
- A. Keep a large tourniquet at the bedside to stop potential bleeding from the amputation site.
- B. Place a pillow in the bed for the client to push the stump against many times per day.
- C. Take and document the client’s vital signs every four (4) hours.
- D. Have the dietary department send high protein, high-carbohydrate meals six (6) times a day.
Correct Answer: B
Rationale: Pushing the stump against a pillow toughens the residual limb, improving prosthesis use and function post-amputation. Tourniquets are for emergencies, vitals are routine, and frequent meals are excessive.
You may also like to solve these questions
The nurse is caring for the client following a knee arthroscopy. What information should the nurse teach? Select all that apply.
- A. Elevate the involved extremity on pillows for 24 to 48 hours.
- B. Apply an ice pack continually to the involved joint for 24 hours.
- C. Report severe joint pain immediately to the health care provider.
- D. Resume usual activities to minimize joint stiffness and swelling.
- E. Treat pain with a mild analgesic such as acetaminophen.
Correct Answer: A,C,E
Rationale: A. Elevation will help to decrease edema. C. Severe joint pain may indicate a possible complication and should be reported immediately. E. Usually a mild analgesic such as acetaminophen (Tylenol) is sufficient for pain control following a diagnostic arthroscopy.
The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a 'pop' and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?
- A. Check the position of the left lower extremity.
- B. Elevate the head of the client's bed.
- C. Adjust the pillow used for abduction.
- D. Administer the prescribed pain medication.
Correct Answer: A
Rationale: A. The nurse's initial action should be to check the extremity's position. Improper movement and repositioning can cause prosthesis dislocation; an audible pop and increased pain are signs of possible dislocation.
Which illustration demonstrates abduction for a 10-year-old who had an SCI?
- A. ROM-1.png
- B. ROM-2.png
- C. ROM-3.png
- D. ROM-4.png
Correct Answer: A
Rationale: Abduction involves moving a limb away from the body's midline, as shown in the correct illustration.
To immobilize the suspected fracture, how should the nurse apply a splint?
- A. Below the knee to above the hip
- B. Above the knee to below the hip
- C. Above the ankle to below the knee
- D. Below the ankle to above the knee
Correct Answer: C
Rationale: A suspected tibia fracture requires splinting from above the ankle to below the knee to stabilize the fracture site without unnecessarily immobilizing the hip or knee, which could restrict mobility or complicate transport.
The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first?
- A. Apply a pressure dressing to the stump
- B. Place a tourniquet above the stump
- C. Notify the physician
- D. Apply an ice pack to the stump
Correct Answer: A
Rationale: Applying a pressure dressing is the first action to control hemorrhage, followed by notifying the physician.