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 B
Explanation
b. Give directions using simple phrases.
The correct answer is b. Give directions using simple phrases.
Explanation:
When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.
Explanation for the other options:
a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.
c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.
d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.
In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes effective communication and enhances the client's ability to understand and follow instructions.
Correct Answer is C
Explanation
The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.
Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.
Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.
Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.
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