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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Essential Interventions:

Monitor fetal heart rate
Administer ampicillin IV
Place client in left lateral position
Request a prescription for ephedrine

Contraindicated Intervention:

Decrease the IV flow rate

Rationale:

Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.

A. "Did anything in particular make you feel this way?" B. "Would you tell me more about the changes you see in your body?" C. "Do you ever think about harming yourself?" D. "How long have you had these feelings of uselessness?"

Correct Answer is C

Explanation

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor. Exhibits The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

Correct Answer is C

Explanation

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