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 ["A","C","D","E"]

Explanation

Fever increases fluid loss through perspiration.

Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.

High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.

The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.

Oxygen saturation within the normal range does not indicate increased fluid requirements.

Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.

Heart rate alone does not indicate increased fluid requirements.

A. Tell the client to discuss the medication side effects with the healthcare provider. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Inform the client that gradual tapering must be used to discontinue the medication. D. Remind the client that feeling better is the therapeutic effect of the medication.

Correct Answer is C

Explanation

The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.

Choice A rationale:

While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.

Choice B rationale:

Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.

Choice C rationale:

Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.

Choice D rationale:

Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.

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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

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

Explanation

Correct Answer is C

Explanation

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