Nokea
The client has had a below-the-knee amputation secondary to arterial occlusive disease. The nurse is instructing the client in stump care. Which of the following statements by the client indicates that she understands how to implement her plan of care?
- A. I should inspect the incision carefully when I change the dressing every other day.'
- B. I should wash the incision, dry it, and apply moisturizing lotion daily.'
- C. I should rewrap the stump as often as needed.'
- D. I should elevate the stump on pillows to decrease swelling.'
Correct Answer: C
Rationale: Rewrapping the stump as often as needed ensures proper compression to shape the stump for a prosthesis and reduce edema, indicating correct understanding of stump care. Inspecting every other day may be insufficient, washing and moisturizing the incision risks infection, and elevating on pillows is not standard for arterial disease.
You may also like to solve these questions
The nurse is teaching a client with a spinal fusion about body mechanics. Which client statement indicates understanding?
- A. I'll bend at the waist to pick up objects.'
- B. I'll keep my back straight when lifting.'
- C. I'll twist my torso to reach objects.'
- D. I'll carry heavy items close to my chest.'
Correct Answer: B
Rationale: Keeping the back straight during lifting protects the surgical site and maintains spinal alignment.
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours?
- A. Seven.
- B. Four.
- C. Two.
- D. One.
Correct Answer: B
Rationale: More than four breakthrough doses (80 mg additional morphine) in 24 hours indicates inadequate baseline pain control, requiring physician notification to adjust the long-acting morphine dose.
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
- A. Total white blood count (WBC) 10,000/mm³.
- B. Redness and swelling beyond the incision line.
- C. Temperature of 102°F (38.9°C).
- D. Client reports of pain at the incision site.
- E. Warmth at the incision site.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (B), fever (C), pain (D), and warmth (E). A WBC of 10,000/mm³ (A) is normal and not indicative of infection.