A nurse is caring for a client who is postoperative following a below-the knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Wrap the residual limb with an elastic bandage in a figure-eight configuration.
Wrap the residual limb with an elastic bandage in a proximal-to-distal direction.
Remove the elastic bandage and re-wrap the residual limb once a day.
Secure the elastic bandage to the lowest joint.
The Correct Answer is A
A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.
B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.
C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.
D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.
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Related Questions
Correct Answer is D
Explanation
A. Restlessness may indicate incomplete recovery or inadequate sedation reversal.
B. A brisk response to stimulus suggests the client is still in a mildly sedated state and not fully recovered.
C. A sluggish response to stimulus also indicates the client is not yet fully alert and oriented.
D. The client being cooperative and oriented is an indication of full consciousness and recovery from sedation, meeting discharge criteria.
Correct Answer is C
Explanation
A. Pernicious anemia affects red blood cell production and does not typically cause blood-tinged urine.
B. Prostate enlargement may cause urinary retention or difficulty urinating, but it does not commonly lead to blood-tinged urine in a catheter bag.
C. A bladder infection (cystitis) can lead to hematuria (blood in the urine), especially when the bladder wall is inflamed.
D. Dehydration can cause concentrated urine but does not usually result in blood-tinged urine.
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