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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Bradycardia, which is a slower than normal heart rate, is not typically a sign of hypoglycemia. Hypoglycemia can actually cause an increase in heart rate due to the release of adrenaline in response to low blood sugar levels.
Choice B Reason
Tremors are a common sign of hypoglycemia and are caused by the release of adrenaline. When blood sugar levels fall too low, the body releases adrenaline as a part of the "fight or flight" response, which can lead to shaking or trembling.
Choice C Reason
Kussmaul's respirations, which are deep and labored breathing patterns, are more commonly associated with diabetic ketoacidosis, not hypoglycemia. This type of breathing is the body's response to acidosis and is not indicative of low blood sugar levels.
Choice D Reason
Polyuria, or excessive urination, is not a sign of hypoglycemia. It is more commonly associated with hyperglycemia, as the body attempts to eliminate excess glucose through urine.
Correct Answer is ["A","B","D","E"]
Explanation
Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.
Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.
Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.
Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.
Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.
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