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 C
Explanation
A) Incorrect - Developing new screening protocols is important, but it doesn't directly indicate that the program has prevented diseases. Screening protocols might catch diseases but don't prevent them.
B) Incorrect - Clients receiving rehabilitation indicates they already had disease complications, which is not a primary prevention outcome.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is related to early detection (secondary prevention), not primary prevention.
Correct Answer is D
Explanation
Situation: Increasing confusion of the client.
The nurse should start by providing the current situation, which is the client's increasing confusion. This is crucial information as it indicates a change in the client's condition and may require immediate attention.
Background: Fall at home as reason for admission.
Next, the nurse should provide the background information, which includes the reason for admission, in this case, the fall at home. This helps the healthcare provider understand the context and potential contributing factors to the client's current condition. Assessment: Currently prescribed medications.
After providing the background, the nurse should discuss the assessment findings. In this case, it would be appropriate to mention the client's currently prescribed medications. This information can help the healthcare provider assess for any medication-related issues or interactions that could be contributing to the client's confusion.
Recommendation: Client's healthcare power of attorney.
Lastly, the nurse should provide the recommendation, which in this case is the client's healthcare power of attorney. This information is important as it identifies the designated decision-maker for the client's healthcare decisions and can assist the healthcare provider in involving the appropriate person in the care planning process.
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