A client in the PACU with a left below-the-knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?
Show the patient that her leg is gone
Administer the prescribed pain medication
Explain and educate the patient that the pain is real
Tell the patient that it is not possible to feel pain in her toes
The Correct Answer is B
Choice A reason: Showing the patient that her leg is gone does not address the immediate concern of pain management.
Choice B reason: Administering the prescribed pain medication is the first step in managing phantom pain, which is a common experience for amputees.
Choice C reason: While it is important to validate the patient's experience of pain, the first action should be to address the pain medically.
Choice D reason: Telling the patient that it is not possible to feel pain in her toes is incorrect and dismissive of the phenomenon of phantom pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.
Choice B reason: The ability to verbalize causes and effects of CHD/CAD is an educational goal, not an immediate care priority.
Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.
Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.
Correct Answer is C
Explanation
Choice A reason (acute renal failure): Patients recovering from acute renal failure are not typically restricted to only vegetable proteins. Protein needs can vary based on the individual's condition and treatment plan.
Choice B reason (acute renal failure): Fluid intake recommendations for patients recovering from acute renal failure depend on their current kidney function and fluid balance status. A blanket restriction to 1500 mL or less per day may not be appropriate for all patients.
Choice C reason (acute renal failure): Avoiding nephrotoxic drugs is crucial for patients recovering from acute renal failure to prevent further kidney damage.
Choice D reason (acute renal failure): Self-catheterization for residual urine is not a standard recommendation for all patients recovering from acute renal failure. This would be specific to patients with urinary retention issues.
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