The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A) You can splint the incision with a pillow when changing position: Splinting the incision with a pillow is an excellent nonpharmacological method to manage pain during position changes after a cesarean section. The pillow helps provide support to the incision site, reduces strain on the abdominal muscles, and minimizes discomfort when the client moves. This is a safe and effective intervention to help with pain management.

B) You should change position as little as possible: While minimizing movement might seem like a way to prevent pain, it can lead to complications like muscle stiffness, poor circulation, and respiratory issues. It’s important for clients to change positions to promote comfort, circulation, and lung expansion, but they should do so with support to manage pain effectively.

C) You should use patterned paced breathing when changing positions: Patterned paced breathing is a helpful relaxation technique that can be used in various situations, including labor and delivery. However, it is not the most appropriate response in this context, as the client’s pain is more related to physical discomfort from the incision, and physical support (like splinting the incision) would be more effective in managing this type of pain.

D) You can apply counterpressure to your back with each position change: While counterpressure can be beneficial for back pain during labor, it is not the most relevant technique for managing pain after a cesarean section, where the pain is related to the abdominal incision site. Splinting the incision provides more targeted support for post-cesarean discomfort.

A) Encourage the client to use overbed trapeze:
Encouraging the client to use an overbed trapeze is an appropriate intervention to promote independence and mobility after an above-the-knee amputation. The trapeze allows the client to move, reposition themselves, and perform activities of daily living more independently, which is important for regaining strength and confidence during the rehabilitation process. It aids in improving upper body strength and assists in early mobility efforts.
B) Maintain abduction of the client's residual limb with a pillow:
Placing a pillow under the residual limb in a position that maintains abduction (separation of the residual limb away from the body) is not recommended after an above-the-knee amputation. This position can lead to contractures of the hip joint, limiting mobility and the ability to use a prosthetic limb in the future. Proper positioning usually involves keeping the residual limb flat or neutral to avoid deformities.

C) Caution the client to avoid a prone position while in bed:
This recommendation is incorrect. In fact, encouraging the client to spend time in the prone position (lying on their stomach) can help prevent hip contractures, especially after an above-the-knee amputation. It is important for the client to position their body in ways that encourage proper limb alignment and prevent long-term complications such as contractures that could impede mobility.

D) Keep a loose, absorbent dressing over the client's surgical site:
A loose, absorbent dressing is not ideal for post-surgical care following an amputation. A dressing should be secure, sterile, and changed regularly to prevent infection and promote optimal wound healing. Keeping a dressing loose could lead to the risk of infection or delayed healing. The nurse should follow the provider’s orders for dressing changes and monitor for signs of infection.