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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. "Only your son can decide to who the laboratory results can be shared with."
Since the client is 18 years old, he is legally an adult and has the right to confidentiality regarding his medical information. The nurse should inform the mother that the son must provide consent before sharing any test results with her.

B. "I can give you those results as soon as I get them back from the laboratory." The nurse cannot release the results to the mother without the client's consent, as he is an adult and his medical information is confidential.

C. "I need to wait for the results of other tests before I can share the information to you." The nurse’s ability to share the results with the mother is based on the client’s consent, not on waiting for other tests.

D. "Let us wait for the healthcare provider to come and share this information with you." While it may be helpful for the healthcare provider to discuss the results, the key issue here is the client's consent. The nurse should clarify that the client is the one who must authorize sharing the results.

A. Perform active range of motion exercises. B. Apply compression stockings. C. Give antispasmodic medications. D. Massage the extremities twice a week.

Correct Answer is C

Explanation

A. Perform active range of motion exercises: Active ROM exercises are beneficial for maintaining joint mobility and circulation, but they may not sufficiently reduce spasticity in clients with upper motor neuron lesions.

B. Apply compression stockings: Compression stockings help prevent venous thromboembolism and manage edema, but they do not treat muscle spasticity. They offer circulatory support, not neuromuscular control, and therefore would not alleviate the client’s current concern.

C. Give antispasmodic medications: Antispasmodics such as baclofen or tizanidine directly target muscle spasticity by acting on the central nervous system. These medications reduce the frequency and intensity of spasms, improving comfort and mobility in clients with spinal cord injuries.

D. Massage the extremities twice a week: Massage may offer relaxation and temporary relief but is not a primary treatment for spasticity. It does not alter the neurophysiological causes of muscle spasms and is unlikely to produce sustained control over involuntary muscle activity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 18-year-old male client is admitted to the hospital with a possible drug overdose. His mother requests to know the results of the toxicology screen test. Which response is best for the nurse to provide?

Correct Answer is A

Explanation

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

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?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notices that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions?