A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting.When the patient arrives on the orthopedic unit after surgery, which action should the nurse take?

Encourage the patient to bear weight on the residual limb to promote early ambulation.

Apply a tight compression bandage to the residual limb to promote circulation.

Assess the residual limb for signs of hemorrhage or poor circulation.

Remove the prosthetic limb and keep the residual limb uncovered to allow for air exposure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging the patient to bear weight on the residual limb immediately after surgery is not recommended due to the risk of injury and poor healing.

Choice B rationale

Applying a tight compression bandage can help with circulation, but assessing for complications takes precedence immediately after surgery.

Choice C rationale

Assessing the residual limb for signs of hemorrhage or poor circulation is crucial to identify any post-surgical complications early.

Choice D rationale

Keeping the residual limb uncovered might be necessary in some cases, but initial assessment and monitoring are more important immediately after surgery. .

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Correct Answer is B

Explanation

Choice A rationale

Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.

Choice B rationale

Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.

Choice C rationale

Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.

Choice D rationale

Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .

A. Complete blood count (CBC). B. Lipid profile. C. Electrocardiogram (ECG). D. Troponin levels.

Correct Answer is D

Explanation

Choice A rationale

A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.

Choice B rationale

A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.

Choice C rationale

An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.

Choice D rationale

Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.

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A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting.When the patient arrives on the orthopedic unit after surgery, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a recent ST segment elevation MI (STEMI) presents with bilateral lower extremity edema and crackles throughout the lung fields.What is the nurse's priority intervention for this client?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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