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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this can help protect the feet from minor injuries, it doesn't directly address the risk of burns from hot water.
B. This can be helpful for foot health, but it doesn't protect against burns.
C. This is the most effective way to prevent burns, as individuals with peripheral neuropathy may not be able to feel the heat of the water.
D. This is important for identifying cuts, sores, or other foot problems, but it doesn't directly prevent burns.
Correct Answer is B
Explanation
This is the correct time to start monitoring for hypoglycemia. The insulin would have started working by this time, and the nurse can assess for any signs of low blood sugar, such as sweating, shakiness, or confusion.
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