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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You can take this medication with milk." This is incorrect because dairy products interfere with the absorption of tetracycline and should be avoided when taking the medication.
B. "You should take this medication at bedtime." This is incorrect because taking tetracycline at bedtime increases the risk of esophageal irritation. It should be taken with a full glass of water while sitting or standing upright.
C. "Constipation is an adverse effect of this medication." This is incorrect because tetracycline is more commonly associated with diarrhea rather than constipation.
D. "Light sensitivity is an adverse effect of this medication." This is correct because tetracycline can cause photosensitivity, making the skin more susceptible to sunburn. Clients should be advised to use sunscreen and wear protective clothing when exposed to sunlight.
Correct Answer is C
Explanation
A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.
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