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 ["A","C","E"]

Explanation

Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.

Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.

Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.

Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.

Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.

A. Place compression stockings on the lower extremities. B. Apply cold compresses to the affected extremity. C. Gently massage the area every 4 hr. D. Inform the client that heparin is prescribed to dissolve the thrombus.

Correct Answer is A

Explanation

Choice A reason: This is the best action, because compression stockings can help improve the blood flow and prevent the formation of new clots in the veins of the legs. Compression stockings can also reduce the swelling, pain, and inflammation caused by thrombophlebitis.

Choice B reason: This is an incorrect action, because cold compresses can cause vasoconstriction and worsen the blood flow and the clotting process in the affected vein. Cold compresses can also increase the discomfort and numbness of the extremity.

Choice C reason: This is an incorrect and dangerous action, because gently massaging the area can dislodge the clot and cause it to travel to the lungs, heart, or brain, resulting in a life-threatening complication, such as pulmonary embolism, myocardial infarction, or stroke.

Choice D reason: This is an incorrect and misleading statement, because heparin is not prescribed to dissolve the thrombus, but to prevent the growth and extension of the existing clot and the formation of new clots. Heparin is an anticoagulant that inhibits the clotting factors in the blood, but does not break down the clot. The body's own enzymes, such as plasmin, are responsible for dissolving the clot.

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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","C","E"]

Explanation

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Correct Answer is A

Explanation

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