A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Discontinue the overhead trapeze.

Turn the client every 6 hr while in bed.

Remind the client that phantom limb pain does not need treatment.

Assist the client to a prone position every 3 hr.

Answer and Explanation

The Correct Answer is D

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

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Correct Answer is B

Explanation

A) Staying current on scheduled immunizations: Staying up-to-date with immunizations is important for overall child health but is not a direct risk factor for sudden infant death syndrome (SIDS). Immunizations can help prevent infections that could contribute to SIDS but are not directly related to the syndrome itself.

B) Maternal smoking during pregnancy: Maternal smoking during pregnancy is a well-documented risk factor for SIDS. Exposure to nicotine and other harmful substances from smoking can affect the baby's respiratory system and increase the likelihood of SIDS.

C) Newborn who is large for gestational age: Being large for gestational age is not a recognized risk factor for SIDS. SIDS risk factors are more closely associated with prenatal and postnatal conditions, rather than birth weight alone.

D) Meconium staining of amniotic fluid: Meconium staining of amniotic fluid is a condition that can indicate fetal distress during labor but is not a direct risk factor for SIDS. It is more related to potential complications during delivery rather than SIDS risk.

A. Give a 25-mg test dose of the medication. B. Flush the IV site with 3 mL of heparin following infusion. C. Instruct the client to remain supine for 10 min after administration. D. Dilute the medication in sterile water for injection.

Correct Answer is D

Explanation

A) Drowsiness: While drowsiness can be a sign of elevated magnesium levels, it is less critical compared to more immediate symptoms like bradycardia. Monitoring and managing drowsiness is important, but bradycardia poses a more immediate risk of severe cardiovascular issues.

B) Diminished patellar reflexes: Diminished reflexes can indicate elevated magnesium levels, but this finding is less urgent compared to symptoms directly affecting heart function. It still needs to be reported but is not the highest priority.

C) Generalized muscle weakness: Muscle weakness is another common sign of high magnesium levels, reflecting the effect of magnesium on neuromuscular function. However, it is less critical compared to bradycardia, which can be life-threatening.

D) Bradycardia: Elevated magnesium levels can significantly impact cardiac function, leading to bradycardia. Bradycardia can be life-threatening, as it may result in decreased cardiac output and potential for severe complications. Therefore, this finding requires immediate attention and should be reported to the provider first.

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A nurse is providing care for a client who is 1-day postoperative following a below-the-knee amputation resulting from musculoskeletal trauma. Which of the following actions should the nurse take?

Nursing Test Bank

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