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 ["A","C"]

Explanation

A. The nurse should notify the prescriber about the current dose (7 mL/hr) because the patient is ordered 1600 units of heparin per hour. The current infusion rate needs to be assessed in relation to the aPTT result, especially if the aPTT indicates that the patient may be at risk for bleeding.
B. While having a second IV may be useful for administering fluids or medications in case of a bleeding emergency, there is no immediate indication for IV 0.9 saline in this scenario. The priority is to assess the heparin dosage and aPTT before making additional IV arrangements.
C. It’s important to assess the IV site for signs of infiltration, especially since the patient is on heparin therapy. Infiltration can affect the effectiveness of the medication and cause complications, so this assessment is vital.
D. While it is important to verify lab results, the nurse should primarily focus on addressing the current situation regarding the heparin infusion and the patient’s anticoagulation status rather than confirming lab results with the lab technician at this moment.
E. While protamine sulfate is an antidote to heparin, it is not warranted based solely on the aPTT result of 37 seconds. The normal aPTT range is typically around 30-40 seconds, depending on the laboratory standards, and the aPTT may not indicate that the patient requires reversal of heparin at this time.

A. 0730 B. 1000 C. 2000 D. 1930

Correct Answer is B

Explanation

This is the correct time to draw the peak level. The peak level is the highest concentration of the drug in the blood, which typically occurs about 30 minutes to an hour after the end of the infusion.

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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?

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Correct Answer is ["A","C"]

Explanation

A client is receiving gentamicin every 12 hours IVPB for an infection. The nurse has administered the 0800 dose, which is prescribed to run over 1 hour. The physician prescribed peak and trough levels to be drawn. The nurse recognizes that the peak level will be drawn at

Correct Answer is B

Explanation

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