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 ["B","D"]

Explanation

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

A. Positive pregnancy test B. Hemoglobin 9.5 g/dL and Hematocrit 32% C. Glycosylated Hemoglobin (A1c) 7.5% D. Serum Cholesterol 237 mg/dL

Correct Answer is A

Explanation

Choice A Reason:
A positive pregnancy test is crucial information that must be reported immediately as it has significant implications for the patient's health and treatment options. Pregnancy can impact the results of a Schilling's test, which is used to diagnose B12 deficiency anemia, as pregnancy itself can cause changes in B12 metabolism. Therefore, the healthcare provider must be informed to adjust the diagnostic approach and ensure the safety of both the mother and the developing fetus.

Choice B Reason:
While a hemoglobin level of 9.5 g/dL is below the normal range for adult females (11.6 to 15 g/dL) and a hematocrit of 32% is at the lower end of the normal range (36% to 44%)[^10^], these results are consistent with anemia but are not as immediately critical as a positive pregnancy test in the context of a Schilling's test.

Choice C Reason:
A glycosylated hemoglobin (A1c) level of 7.5% is above the normal range (4% to 5.9%), indicating poor blood sugar control over the past two to three months, which could suggest diabetes or prediabetes. However, this is not as urgent as a positive pregnancy test when considering the administration of a Schilling's test.

Choice D Reason:
A serum cholesterol level of 237 mg/dL is considered borderline high (200 to 239 mg/dL), which may increase the risk of heart disease over time. However, this does not require immediate reporting in the context of a Schilling's test for B12 deficiency anemia as compared to a positive pregnancy test.

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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 implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Correct Answer is ["B","D"]

Explanation

The nurse is reviewing the laboratory findings for a 34-year-old woman who is scheduled for a Schilling's test for B12 deficiency anemia. Which result should the nurse report immediately to the primary care provider?

Correct Answer is A

Explanation

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