The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

Instruct the client how to perform biofeedback exercises

Place the client's residual limb in the dependent position

Explain to the client his left leg has been amputated

Medicate the client with narcotic analgesic immediately

Answer and Explanation

The Correct Answer is D

A.   While biofeedback can be a helpful technique for managing pain in the long term, it is not an immediate intervention for acute pain. The client is expressing urgent pain that requires prompt action, so this option does not address the immediate need.
B.   Placing the residual limb in a dependent position (below the level of the heart) can increase swelling and may worsen the pain. After surgery, the limb should typically be elevated to minimize swelling, especially in the early postoperative period.

C.   While it is important for clients to understand their situation, explaining the amputation does not provide immediate relief for acute pain. The client is likely already aware of the amputation and is in distress, so this option is not a priority at this moment.
D.   This is the most appropriate intervention. The client is experiencing significant pain, and administering a narcotic analgesic can provide immediate relief. Pain management is a priority in the postoperative setting, especially in the first few hours after surgery.

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Correct Answer is C

Explanation

A. While anxiety can exacerbate feelings of breathlessness, treating anxiety does not address the
underlying issue of respiratory distress. It is important to first stabilize the client’s respiratory condition
before managing anxiety.
B. Auscultating breath sounds can provide valuable information regarding the client’s respiratory status. However, in an emergency situation, immediate interventions to stabilize the client should take precedence over assessments, especially since the vital signs indicate significant distress.

C. Elevating the head of the bed can help improve respiratory effort by allowing better lung expansion and reducing the work of breathing. Given the client’s low oxygen saturation and signs of respiratory distress, this intervention can provide immediate relief and improve oxygenation.
D. While this may be necessary if the client's condition worsens or does not improve, it is not the first action to take. Preparing for mechanical ventilation is a more advanced intervention and should only occur after initial stabilization efforts have been made.

A. increased. B. given as prescribed. C. cut in half. D. held.

Correct Answer is D

Explanation

A. An INR of 5.0 indicates that the blood is significantly thinner than the therapeutic range (typically 2.0 to 3.0 for DVT treatment). Increasing the dose of warfarin would further increase the risk of bleeding.
B. Continuing with the prescribed dose of 2.5 mg is not appropriate at this time. The INR is above the safe therapeutic range, indicating a need for adjustment, not maintenance of the current dose.
C. While reducing the dose may be necessary, cutting it in half may not adequately address the high INR. The more appropriate action would involve holding the dose or significantly adjusting it based on the INR and clinical guidelines.
D. An INR of 5.0 is a critical value that suggests the client is at an increased risk of bleeding. The appropriate action in this case is to hold the warfarin dose and notify the healthcare provider for further evaluation and management. Depending on clinical protocols, the provider may recommend administering vitamin K to reverse the effects of warfarin, especially if there are signs of bleeding or if the INR is critically high.

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The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be:

Correct Answer is D

Explanation

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