Med Surg EAQ Ch. 46

Which response explains the purpose of a compression dressing for a residual limb?

"The compression dressing is used to promote healing and to help shrink and taper the residual limb."

Which statement by the patient who has undergone replantation surgery indicates the need for further education?

"I should avoid taking aspirin."

What is the greatest danger in the early postoperative period following an amputation?

Hemorrhage

Which postamputation complication does the nurse suspect when a patient exhibits bluish discoloration of the skin and a blood pressure of 96/64 mm Hg?

Hemorrhage

A patient who has undergone amputation of the left arm tells the nurse, "I am feeling severe pain and a weird sensation in my left arm that makes me feel like I am going crazy." Which response would the nurse tell the patient?

"This feeling will likely go away soon after you start moving."

Twenty-four hours post above-the-knee amputation surgery, the patient is complaining that his left foot is itching and asks why this is happening. Which response would the nurse provide?

"You are experiencing phantom limb sensation, a completely normal response after amputation."

Which teaching would the nurse provide to a patient after amputation?

"You may develop hip or knee contracture if you sit for long periods."

Which are most commonly involved in accidents and injuries that lead to traumatic limb amputations? Select all that apply.

1. Firearms 2. Frostbite 3. Motorcycles 4. Power tools 6. Farm machinery

Which signs and symptoms are observed in a patient with phantom limb sensation? Select all that apply.

1. Itching 2. Tingling 4. Numbness

Which instructions would the nurse give the patient who has undergone replantation of a thumb? Select all that apply.

1. Keep the thumb positioned as instructed by the provider. 2. Avoid caffeine for 7 to 10 days or as directed by the provider. 3. Avoid tight clothing around the wrist area of the affected hand. 5. Call the health care provider if a change in color or warmth of the thumb is noted.

The nurse would assess a patient after an above-the-knee amputation for which complications? Select all that apply.

1. Pain 2. Edema 4. Infection 6. Hemmorrhage

After amputation, which interventions decrease the possibility of a patient developing contractures during the healing process? Select all that apply.

1. Sleeping on a firm mattress 2. Having a trapeze bar installed 4. Lying prone for 30 minutes 3 to 4 times a day

The integumentary assessment focuses on which specific areas? Select all that apply.

1. Tugor 2. Texture 3. Skin color 4. Temperature

Which conditions or situations may lead to an amputation? Select all that apply.

1. Tumor 2. Trauma 3. Disease 5. Congenital anomalies

Which diseases most often lead to impaired circulation and possible amputation? Select all that apply.

2. Arteriosclerosis 3. Vascular disease 4. Diabetes mellitus

The nurse is assessing the closed incision site of a patient 48 hours after a below-the-knee amputation. Which assessment finding would concern the nurse? Select all that apply.

2. Foul odor from dressing 3. Swollen and red residual limb 4. Sudden temperature elevation 5. Elevated white blood cell count

Which signs indicate decreased cardiac output in a patient who has undergone an amputation? Select all that apply.

2. Hypotension 3. Increased pulse 5. Increased respiratory rate

Which complications would the nurse teach the patient about an above-the-knee amputation? Select all that apply.

2. Swelling 3. Infection 4. Contracture 5. Hemorrhage 6. Phantom limb pain

A patient can usually bear full weight on a permanent prosthesis in approximately which amount of time after amputation?

3 months

Provided that no problems occur, in which time period after an amputation can a patient usually bear full weight on a permanent prosthesis?

3 months

Which diet promotes healing and helps maintain or build strength after an amputation?

A diet that is high in calories and protein

Which patient is at the highest risk for an upper extremity amputation?

A young adult man working with explosives

Which information is priority to collect on the patient who had a foot amputated 5 years ago?

Conditions that resulted in the need for an amputation

When providing emotional support to a patient preparing to undergo amputation surgery, which action is appropriate?

Allow the patient to express anger.

Which intervention for the residual limb is beneficial for a patient after below-the-knee amputation?

Apply a compression dressing

In order for the bilateral leg amputee patient to transfer safely, what exercises should the physical therapist include in the patient's care?

Arm presses

The nurse is assessing the compression dressing for a patient 4 hours after a below-the-knee amputation and notes a small amount of drainage. Which nursing action is correct?

Circling the drainage with a pen

Which neurovascular assessment finding would concern the nurse?

Cold to touch

Which nursing action is appropriate after determining the capillary refill of a patient who has a cast on his left foot is 2 seconds?

Document the findings.

Which diagnostic test is used to locate the peripheral pulses?

Doppler ultrasound

Which complication can be prevented by applying a heavy cast on the residual limb after an amputation?

Edema

How does massaging the residual limb help a patient who underwent amputation?

It promotes blood circulation.

Which aspect of care is considered the priority in the early postoperative period after amputation?

Monitor vital signs for changes.

Which complication of amputation requires surgical debridement?

Necrosis

Which type of amputation should the nurse anticipate caring for postoperatively if the patient is diagnosed with gangrene?

Open amputation

Which discipline is usually charged with initiating an exercise program?

Physical therapy

Which information should the nurse include in the teaching plan for a patient who underwent a below-the-knee amputation?

The patient should wash and dry the socket of the prosthesis before use.

Which finding indicates diminished blood flow to the extremities?

The patient's capillary refill time is 5 seconds.

A liquid dietary supplement after amputation may be prescribed for which reason?

The patient's diet is inadequate for healing.

The nurse is caring for a patient with a right, below-the-knee amputation. The patient most likely suffers from which disorder?

Vascular disease