A client who is to have an amputation of the lower extremity asks the nurse. "How much of my leg will the doctor have to amputate?" The nurse's response is based on the knowledge that the level of amputation is determined by the:
ease with which a prosthesis can be fitted.
adequacy of the blood supply to the stump for healing.
need to remove as much of the leg as possible.
client's ability to walk with a prosthesis.
The Correct Answer is B
A. While the ease of fitting a prosthesis is a consideration, it is not the main factor. The level of amputation is primarily determined by medical considerations, particularly related to health and healing.
B. This is the primary determinant for the level of amputation. Surgeons aim to preserve as much limb length as possible while ensuring that the remaining tissue has adequate blood supply for healing.
Insufficient blood supply can lead to complications, including poor healing and infection, making this a critical factor in deciding the amputation level.
C. This option suggests a more aggressive approach than necessary. The goal is to remove only as much of the limb as required to address the medical issue (e.g., disease, trauma) while preserving as much healthy tissue as possible for optimal healing and function.
D. While a client’s functional ability with a prosthesis is an important consideration in rehabilitation planning, it is not the main factor in deciding the surgical level of amputation. The decision about how much limb to remove is made based on medical criteria, particularly healing potential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the correct time to draw the peak level. The peak level is the highest concentration of the drug in the blood, which typically occurs about 30 minutes to an hour after the end of the infusion.
Correct Answer is ["A","C"]
Explanation
A. The nurse should notify the prescriber about the current dose (7 mL/hr) because the patient is ordered 1600 units of heparin per hour. The current infusion rate needs to be assessed in relation to the aPTT result, especially if the aPTT indicates that the patient may be at risk for bleeding.
B. While having a second IV may be useful for administering fluids or medications in case of a bleeding emergency, there is no immediate indication for IV 0.9 saline in this scenario. The priority is to assess the heparin dosage and aPTT before making additional IV arrangements.
C. It’s important to assess the IV site for signs of infiltration, especially since the patient is on heparin therapy. Infiltration can affect the effectiveness of the medication and cause complications, so this assessment is vital.
D. While it is important to verify lab results, the nurse should primarily focus on addressing the current situation regarding the heparin infusion and the patient’s anticoagulation status rather than confirming lab results with the lab technician at this moment.
E. While protamine sulfate is an antidote to heparin, it is not warranted based solely on the aPTT result of 37 seconds. The normal aPTT range is typically around 30-40 seconds, depending on the laboratory standards, and the aPTT may not indicate that the patient requires reversal of heparin at this time.
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