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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Ambulating soon after surgery is encouraged to promote circulation and decrease the risk of VTE.

B. Massaging the legs is unsafe, as it can dislodge any existing clot, potentially leading to a pulmonary embolism.

C. Elevating the feet helps improve venous return and is a safe practice to reduce VTE risk.

D. Flexing the ankles is part of exercises that help promote blood flow and reduce clot formation risk.

A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Place the client in a sitting position. D. Check the client's bladder for distention.

Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

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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?

Nursing Test Bank

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