The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)
Inspect skin for redness.
Use a residual limb shrinker.
Avoid range of motion exercises.
Apply alcohol to the residual limb after bathing.
Correct Answer : A,B
The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.
Choice A rationale:
Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.
Choice B rationale:
Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.
Choice C rationale:
Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.
Choice D rationale:
Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.
Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.
Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
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