A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

Turn the client every 4 hr while in bed.

Place the client on an air mattress.

Instruct the client to use an overbed trapeze to move around in bed.

Rewrap the bandage every 8 hr in a circular pattern.

Answer and Explanation

The Correct Answer is C

A. Turning the client every 4 hours is too infrequent for a postoperative patient. The client should be turned at least every 2 hours to prevent complications such as pressure injuries.
B. An air mattress may help prevent pressure ulcers, but it does not specifically address postoperative care for an amputation.
C. Using an overbed trapeze allows the client to move independently, reducing strain on the residual limb and promoting mobility while preventing pressure injuries.
D. The bandage should be rewrapped every 4 to 6 hours in a figure-eight pattern, not every 8 hours in a circular pattern, to promote proper shaping of the residual limb and prevent circulation issues.

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Correct Answer is B

Explanation

A. Choose the client's dominant arm for IV access whenever possible. The nondominant arm is preferred to minimize interference with daily activities.
B. Select a site proximal to previous venipuncture sites. This is the appropriate action because using a site above a previous one ensures better vein integrity and reduces complications.
C. Initiate IV access on the palmar side of the client's wrist. This site should be avoided as it is more painful and increases the risk of nerve damage.
D. Insert a larger gauge IV catheter to prevent phlebitis. A smaller gauge catheter is preferred when possible, as larger catheters can increase the risk of vein irritation and phlebitis.

A. A bologna sandwich on rye bread B. Whole wheat pasta with shrimp C. A corn tortilla with black beans D. Low sodium vegetable soup with barley

Correct Answer is C

Explanation

A. A bologna sandwich on rye bread. This is incorrect because rye bread contains gluten, which must be avoided in a celiac disease diet.
B. Whole wheat pasta with shrimp. This is incorrect because whole wheat pasta contains gluten, making it unsuitable for a child with celiac disease.
C. A corn tortilla with black beans. This is correct because corn tortillas are naturally gluten-free, and black beans provide a nutritious, safe option for a child with celiac disease.
D. Low sodium vegetable soup with barley. This is incorrect because barley contains gluten, making it inappropriate for a celiac-friendly diet.

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A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

Nursing Test Bank

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