A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Dry the prosthesis socket completely before applying it to the limb.

Apply a moisturizing lotion or oil to the stump daily.

Keep the prosthesis in direct contact with the residual limb.

Expect some skin irritation from the prosthesis.

Answer and Explanation

The Correct Answer is A

Choice A reason:
It is essential to dry the prosthesis socket completely before applying it to the limb to prevent any moisture-related issues, such as skin irritation or infection. Moisture can create an environment conducive to bacterial growth and can also cause the prosthesis to slip or not fit properly.

Choice B reason:
While it is important to keep the skin of the stump moisturized, applying lotion or oil immediately before putting on the prosthesis is not advised. Lotions and oils can make the skin slippery, leading to a poor fit of the prosthesis or even causing the prosthesis to slip off. It is better to apply moisturizer at a time when the prosthesis will not be worn for a while, allowing the skin to absorb the lotion fully.

Choice C reason:
The prosthesis should not be in direct contact with the residual limb without proper padding or a liner. Direct contact can lead to pressure sores, skin irritation, and discomfort. Properly fitted socks or liners should be used to cushion the limb and ensure a comfortable, secure fit.

Choice D reason:
While some skin irritation may be expected when first using a prosthesis, persistent irritation is not normal and should be addressed by a healthcare provider. The prosthesis may need to be adjusted, or there may be an issue with the fit or the materials used. Skin irritation should not be accepted as a standard part of using a prosthesis.

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Correct Answer is C

Explanation

Choice A reason:
Bradycardia, or a heart rate that is slower than normal, is not a common finding in anemia. Anemia typically results in a compensatory increase in heart rate, known as tachycardia, to maintain adequate oxygen delivery to tissues.

Choice B reason:
Diarrhea is not a direct symptom of anemia. While it can be a postoperative complication due to various reasons, such as medication side effects or infections, it is not a symptom associated with anemia resulting from excess blood loss.

Choice C reason:
Fatigue is a hallmark symptom of anemia, regardless of the cause. When anemia is due to excess blood loss, the body's oxygen-carrying capacity is diminished due to the reduced number of red blood cells. This leads to fatigue, as tissues and organs receive less oxygen than is needed for optimal function.

Choice D reason:
Hypertension is not typically associated with anemia. In fact, anemia can sometimes lead to hypotension, or low blood pressure, because of the reduced volume of red blood cells in the circulatory system.

A. Who was the individual who assaulted you? B. What day and time did the assault take place? C. Where did the assault occur? D. Do you give us permission to call the police?

Correct Answer is B

Explanation

Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.

Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.

Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.

Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.

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A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Which of the following questions is most important to ask a client who might have been exposed to HIV after being sexually assaulted?

Correct Answer is B

Explanation

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