A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Instruct the client to stay in the bathtub no longer than 20 min.

Fill the bathtub with water at 48 C (118.4° F).

Use bath oil in the client’s bathtub

Provide the client with non-slip bath strips in the bathtub.

Answer and Explanation

The Correct Answer is D

A.   The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B.   Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C.   Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D.   Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

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Correct Answer is ["B","C","G","H"]

Explanation

A. Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B. Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C. Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D. Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E. Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F. Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G. Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H. Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.

A. A client who has swelling and tenderness around the wound B. A client who has brown crusting over the wound C. A client who has serosanguineous drainage from the wound D. A client who has urticaria and itching around the wound

Correct Answer is A

Explanation

A. Swelling and tenderness around the wound are common signs of infection, indicating an inflammatory response to the presence of bacteria.
B. Brown crusting over the wound may suggest the presence of a scab or dried exudate, which is a normal part of the healing process and not necessarily indicative of infection.
C. Serosanguineous drainage is a type of wound drainage that is typically not a sign of infection but rather a mix of clear and blood-tinged fluid.
D. Urticaria and itching around the wound suggest an allergic reaction rather than a wound infection.

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A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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