Which nursing action(s) should the nurse include in the post-op plan of care for a client recovering from a below-the-knee amputation?

Administering pain medication as needed.

Encouraging the client to bear weight on the affected limb immediately after surgery.

Restricting the client's mobility and keeping the client on bed rest.

Applying a tight compression bandage on the residual limb.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Post-operative pain management is a critical aspect of care for a client recovering from a below-the-knee amputation. Administering pain medication as needed helps to manage pain effectively, which is essential for the client's comfort and recovery. Pain control is also important to facilitate participation in rehabilitation activities.

Choice B reason:

It is not advisable to encourage the client to bear weight on the affected limb immediately after surgery. The residual limb needs time to heal, and premature weight-bearing can lead to complications such as delayed healing or wound dehiscence.

Choice C reason:

While it is important to prevent complications such as deep vein thrombosis, complete restriction of mobility and keeping the client on bed rest is not recommended. Early mobilization, as part of a rehabilitation program, is essential for improving circulation, preventing muscle atrophy, and promoting overall recovery.

Choice D reason:

Applying a tight compression bandage on the residual limb is a common practice in the post-operative care of clients with amputations. The compression bandage helps to control swelling, shape the limb for a prosthesis, and prevent fluid accumulation. However, the bandage must be applied correctly to avoid impairing circulation.

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Correct Answer is D

Explanation

Choice a reason:
For individuals with Crohn's disease, eating three large meals may not be the best approach as it can overwhelm the digestive system. Smaller, more frequent meals are often recommended to ease the digestion process and better manage symptoms.

Choice b reason:
Drinking water during meals can help with digestion, but there is no specific requirement to limit it to ten ounces. Adequate hydration is important, but the amount should be tailored to individual needs and tolerances.

Choice c reason:
Choosing coffee over cola is not necessarily beneficial for Crohn's disease management. Both beverages can potentially irritate the gastrointestinal tract, and individuals with Crohn's disease are often advised to limit caffeine and carbonated drinks.

Choice d reason:
Increasing protein intake can be beneficial for clients with Crohn's disease, especially if they have experienced weight loss or malnutrition due to their condition. Protein is essential for healing and repair of tissues, and maintaining adequate protein levels is important for overall health.

A. Maintain normal salt and fluid intake in the diet. B. Drink twice the usual amount of fluids daily. C. Avoid eating aged cheese, processed meats, and red wine. D. Double the lithium dose if diarrhea or vomiting occurs.

Correct Answer is A

Explanation

Choice A Reason:
Maintaining normal salt and fluid intake is crucial for patients on lithium. Lithium can affect sodium levels in the body, and consistent sodium intake helps to keep lithium levels stable. Patients should be advised to drink adequate fluids to prevent dehydration but avoid excessive fluid intake, which could alter lithium levels and potentially lead to toxicity¹²³⁴.

Choice B Reason:
Drinking twice the usual amount of fluids daily is not recommended for patients on lithium unless directed by a healthcare provider. Excessive fluid intake can lead to changes in lithium levels and increase the risk of lithium toxicity. Patients should aim to consume a sufficient amount of fluids to stay hydrated, especially in situations that may lead to dehydration, such as during hot weather or illness.

Choice C Reason:
Avoiding aged cheese, processed meats, and red wine is generally advised for patients taking monoamine oxidase inhibitors (MAOIs), not lithium. These foods can contain high levels of tyramine, which can interact with MAOIs. However, there are no specific dietary restrictions for lithium regarding these foods. Patients should follow a balanced diet and consult with their healthcare provider for personalized dietary advice.

Choice D Reason:
Doubling the lithium dose if diarrhea or vomiting occurs is incorrect and potentially dangerous. If a patient experiences diarrhea or vomiting, it can affect lithium absorption and increase the risk of toxicity. Instead, patients should contact their healthcare provider for guidance. Adjustments to the medication regimen should only be made under medical supervision.

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Which nursing action(s) should the nurse include in the post-op plan of care for a client recovering from a below-the-knee amputation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is diagnosed with Crohn's disease. Which statement made by the client indicates an understanding of the teaching? "I will:

Correct Answer is D

Explanation

The nurse's teaching plan for a client taking lithium should include instructions to:

Correct Answer is A

Explanation

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