A client undergoes an above-the-knee amputation (AKA) of the right leg because of peripheral vascular disease. On the second postoperative day, the nurse enters the room to take the client's vital signs and finds the client lying in a prone position. The client asks for assistance in turning. Which action should the nurse take first?

Determine how long the client has been lying prone.

Measure the client's vital signs.

Inspect the dressing on the stump.

Assist the client in turning to a position of comfort.

Answer and Explanation

The Correct Answer is A

A. Determine how long the client has been lying prone: Prone positioning is used post-amputation to prevent hip flexion contractures. However, prolonged periods in this position can cause discomfort or complications. Knowing the duration helps evaluate if it’s appropriate to reposition or maintain it for therapeutic reasons.

B. Measure the client's vital signs: Vital signs are important in the postoperative period, but this task can be completed after addressing the client’s immediate request and assessing the potential impact of their current positioning on healing and comfort.

C. Inspect the dressing on the stump: Inspecting the stump is crucial for monitoring for infection or bleeding. However, unless there is a concern based on symptoms or reports from the client, it should follow assessment of position and comfort needs.

D. Assist the client in turning to a position of comfort: Turning the client without assessing how long they have been prone could interfere with therapeutic positioning aimed at preventing complications like hip contractures, especially in early postoperative care.

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Correct Answer is A

Explanation

A. Chest tube insertion tray: Thoracentesis may lead to complications like pneumothorax, especially in clients with lung disease such as emphysema. If air or fluid reaccumulates or lung collapse occurs, a chest tube may be urgently required to re-expand the lung and drain air or fluid buildup.

B. Intubation tray: While intubation may be needed in cases of severe respiratory failure, it is not the first-line equipment after an ineffective thoracentesis. It would only be used if the patient is unable to breathe adequately despite other interventions.

C. Ventilator: Mechanical ventilation is not immediately needed for a failed thoracentesis unless the client develops respiratory failure. It is a secondary measure if oxygenation cannot be maintained with basic support.

D. Crash cart: A crash cart is essential during cardiac arrest or life-threatening emergencies. It is not the most appropriate equipment to have specifically for an ineffective thoracentesis unless severe complications arise suddenly.

A. The woman is timid and speaks softly when asked about the accident. B. spiral fracture on the woman's arm and wrist. C. The woman is hyperventilating and appears to be in pain. D. Fresh bruises on the woman's shoulder and chest.

Correct Answer is B

Explanation

A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.

B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.

C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.

D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.

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Naxlex Comprehensive Predictor Exams

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Correct Answer is A

Explanation

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Correct Answer is B

Explanation

Which oral medication can the nurse safely cut in half?

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?