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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E"]

Explanation

A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.

Correct Answer is ["400"]

Explanation

To calculate the mL/hr rate for the infusion pump, we can use the following formula: mL/hr = (Total volume to be infused in mL) / (Time in hours)

In this case, the total volume to be infused is 200 mL, and the infusion time is 30 minutes, which is equal to 0.5 hours.

mL/hr = 200 mL / 0.5 hours mL/hr = 400 mL/hr

Therefore, the nurse should program the infusion pump to deliver 400 mL/hr.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Correct Answer is ["400"]

Explanation

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Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

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