A nurse is reinforcing discharge teaching with a client who had an above-the-knee amputation and has a prosthesis. Which of the following instructions should the nurse include?
"Keep initial pressure dressing in place for 1 week after surgery."
"Leave the prosthesis in place when going to bed."
"Avoid extension of the hips when lying down."
"Clean the prosthesis using a damp, soapy cloth."
The Correct Answer is D
Answer: D. "Clean the prosthesis using a damp, soapy cloth."
Rationale:
A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.
B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.
C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.
D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Oil-based lubricant
Explanation:
The correct answer is a. Oil-based lubricant.
When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.
Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a different procedure and indication
Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.
Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body fluids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.
By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.
Correct Answer is D
Explanation
d. Increased joint stiffness due to loss of elasticity in joint cartilage.
Explanation:
The correct answer is d. Increased joint stiffness due to loss of elasticity in joint cartilage.
When teaching an older adult client about age-related changes, it is important for the nurse to provide accurate and relevant information. Joint stiffness is a commonly experienced age-related change that occurs due to the natural loss of elasticity in joint cartilage. As people age, their joints may become stiffer and less flexible, making movements and activities more challenging.
Option a is not the correct answer. Increased nail growth due to the buildup of calcium deposits is not an expected age-related change. Nail growth is primarily determined by factors such as genetics, overall health, and nutritional status, rather than calcium deposits.
Option b is not the correct answer. Increased perspiration due to overproduction by the sweat glands is not an expected age-related change. In fact, older adults may experience a decrease in the production of sweat, which can make them more susceptible to heat-related illnesses and dehydration.
Option c is not the correct answer. Increased cardiac output due to weakened heart walls is not an expected age-related change. With aging, the heart muscles may become stiffer and less efficient, leading to a decrease in cardiac output rather than an increase.
By focusing on the expected age-related change of increased joint stiffness due to loss of elasticity in joint cartilage, the nurse can provide accurate information and help the older adult client understand and manage this common aspect of the aging process.
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