The nurse is caring for a client who has returned to the nursing unit from the post anesthesia care unit (PACU) 40 minutes ago following an above the knee amputation (AKA) of the right leg. In which position should the nurse place the client at this time?
Prone with arms elevated
Supine with the stump flat on the bed
Supine with the stump supported on pillows
Reverse Trendelenburg
The Correct Answer is C
A. While positioning a patient prone can help with certain surgical recovery situations, it is not typically used immediately after an above-the-knee amputation. Additionally, elevating the arms may not provide any benefit and could cause discomfort.
B. This position can increase the risk of contractures in the residual limb, especially with an above-the- knee amputation. Keeping the stump flat may also lead to swelling and discomfort.
C. This position allows for proper elevation of the stump, which can help reduce swelling and promote healing. Supporting the stump on pillows prevents the risk of contractures and maintains the limb in a neutral position. It provides comfort and stability while facilitating blood flow.
D. While this position can help with venous return and reduce the risk of complications such as orthostatic hypotension, it is not specifically beneficial for an above-the-knee amputation recovery. It may not adequately address the need for proper stump support and elevation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["37.5"]
Explanation
Drip rate (drops per minute) = (Volume to be infused (mL) x Drop factor) / Time (minutes)
3 hours = 3 * 60 = 180 minutes
Drip rate = (450 mL x 15 drops/mL) / 180 minutes Drip rate = 6750 / 180
Drip rate = 37.5 drops per minute
Therefore, the nurse should regulate the IV at a rate of 37.5 drops per minute.
Correct Answer is A
Explanation
A. The client's fasting blood glucose levels (70-80 mg/dl) are within the normal range, and a post- prandial blood glucose level below 200 mg/dl is also considered well-controlled, particularly for someone on an intensified insulin regimen. The hemoglobin A1c level of 4.5% indicates excellent long- term glucose control, typically representing average blood glucose levels of around 90 mg/dl.
B. Hyperglycemia is characterized by elevated blood glucose levels. Given the client's consistently normal fasting and post-prandial levels, they are not at an increased risk for hyperglycemia. Instead, they are maintaining their glucose levels well.
C. Insulin resistance typically manifests as elevated blood glucose levels despite adequate insulin levels or increased insulin requirements. In this case, the client's blood glucose levels are well-controlled, indicating that they are likely responding well to insulin therapy and are not showing signs of insulin resistance.
D. While the client’s blood glucose levels are well-controlled, the risk for hypoglycemia depends on various factors, including insulin dosage, timing, and food intake. However, consistently normal levels do not directly indicate a risk for hypoglycemia unless insulin doses are excessively high or meals are skipped. Therefore, this choice is not justified given the data provided.
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