The client has returned from surgery following a below the knee amputation (BKA). The residual limb is covered with a compression dressing. Immediately upon return from surgery, the dressing is dry. Thirty minutes later, a small amount of bloody drainage is noted on the dressing. What should be the nurse's priority action at this time?

Change the dressing

Notify the physician

Lower the head of the bed

Mark the area of drainage, time and date

Answer and Explanation

The Correct Answer is D

A.   While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B.   While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C.   Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D.   Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

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Correct Answer is A

Explanation

A. Clients with PAD often experience claudication (pain in the legs due to inadequate blood flow) during exercise. They should be encouraged to walk to the point of pain, then rest until the pain subsides, and then continue walking. This approach can improve circulation over time.
B. While it’s crucial to monitor leg ulcers, exercise can still be beneficial unless advised otherwise by a healthcare provider. Walking can promote circulation, which is important for healing. However, if a leg ulcer is present, the client should consult their healthcare provider about appropriate activity levels.
C. While elevating the feet can help reduce swelling, it's generally more beneficial for clients with PAD to keep their legs in a dependent position after walking. This position encourages blood flow to the legs, which can help alleviate symptoms and improve circulation.
D. Exercise that encourages movement and maintains blood flow to the legs is important for those with PAD. While certain positions may exacerbate symptoms, exercises like walking should be encouraged. Keeping the feet in a dependent position can help with blood flow post-exercise.

A. would need so much of an oral antihypoglycemic agent that it would cost too much. B. are allergic to oral antihypoglycemic agents. C. would have more episodes of hypoglycemia with oral antihypoglycemic agents. D. have little or none of their own insulin that can be released.

Correct Answer is B

Explanation

A. The effectiveness of oral antihypoglycemic agents does not depend on dosage amounts that would make them cost-prohibitive. Instead, these medications work by stimulating insulin production or enhancing insulin sensitivity, which is not relevant for Type 1 diabetes.
B. While some individuals may have allergies to certain medications, this is not the reason oral antihypoglycemic agents are ineffective for those with Type 1 diabetes. The ineffectiveness is not related to allergy but rather to the underlying pathology of the disease.
C. While it is true that the risk of hypoglycemia exists with all glucose-lowering therapies, this is not the primary reason why oral antihypoglycemics are ineffective in Type 1 diabetes. The use of these agents may increase hypoglycemia risk in a broader context, but the fundamental issue is related to insulin deficiency.
D. In Type 1 diabetes, the pancreas produces little to no insulin due to autoimmune destruction of insulin-producing beta cells. Oral antihypoglycemic agents typically rely on the presence of some endogenous insulin to be effective.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client who is diagnosed with peripheral arterial disease about the benefits of walking to exercise. What information should the nurse reinforce with this client?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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