A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?

Elevate the residual limb on a soft pillow.

Assist the client to a prone position every 4 hr.

Reapply a bandage to the residual limb every 12 hr.

Apply dressings to the site in a proximal-to-distal direction.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.

Choice B reason: This is the correct action, because assisting the client to a prone position every 4 hr can prevent hip flexion contractures and promote the range of motion of the hip joint. The client should lie prone for 20 to 30 minutes at a time, with the residual limb extended.

Choice C reason: This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.

Choice D reason: This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect route, because maternal-fetal transmission of hepatitis A is very rare and occurs only if the mother has acute hepatitis A during the third trimester of pregnancy.

Choice B reason: This is the correct route, because fecal-oral contamination of hepatitis A is the most common mode of transmission. Hepatitis A is a viral infection that affects the liver and is spread through ingestion of contaminated food or water, or contact with infected feces.

Choice C reason: This is an incorrect route, because genital sexual contact of hepatitis A is uncommon and occurs only if there is oral-anal contact with an infected person.

Choice D reason: This is an incorrect route, because blood to blood transmission of hepatitis A is also uncommon and occurs only if there is exposure to infected blood or blood products, such as through needle sharing or transfusion.

A. Chicken breast and corn on the cob B. Shrimp and rice C. Cheese omelet and turkey bacon D. Liver and onions

Correct Answer is A

Explanation

Choice A reason: This is the correct meal selection, because chicken breast and corn on the cob are low in cholesterol and saturated fat, which can help lower the risk of heart disease.

Choice B reason: This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.

Choice C reason: This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.

Choice D reason: This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.

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A nurse is contributing to the plan of care for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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