Med Surg Success: Amputation

46. The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three times a day.

1. Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual limb against harder and harder surfaces is done in preparation for prosthesis training. 2. An Ace bandage applied distal to proximal will help decrease edema and help shape the residual limb into a conical shape. 3. Vitamin E oil will help decrease the angriness of the scar, but it will not help with residual limb toughening. 4. Elevating the residual limb will help decrease edema, but it will also cause a contracture if the residual limb is elevated after the first 24 hours. TEST-TAKING HINT: The stem of the question asks the test taker to choose a method of toughening the residual limb. Demonstrating how to apply an elastic bandage or elevating the limb would not accomplish this, so options "2" and "4" could be eliminated from consideration.

39. The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? 1. Assess the client's nutritional status. 2. Refer the client to an occupational therapist. 3. Determine if the client is allergic to IVP dye. 4. Start a 22-gauge Angiocath in the right arm.

1. For wound healing, a balanced diet with adequate protein and vitamins is essential, along with meals appropriate for type 2 diabetes. 2. An occupational therapist addresses activities of daily living and usually addresses upper extremity amputations. A referral to a physical therapist is most appropriate to address ambulating and transfer concerns. 3. There is no type of intravenous dye used in this surgical procedure, so this answer is not appropriate. 4. An 18-gauge catheter should be started because the client is going to surgery; the client may need a blood transfusion, which should be administered through an 18-gauge catheter. TEST-TAKING HINT: The nurse must take into account all the client's comorbid conditions (diabetes type 2) when selecting the correct answer.

48. The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. 1. Report any pain not relieved with analgesics. 2. Eat a well-balanced diet and increase protein intake. 3. Be sure to attend all outpatient rehabilitation appointments. 4. Encourage the client to attend a support group for amputations. 5. Stay at home as much as possible for the first couple of months.

1. Pain not relieved with analgesics could indicate complications or could be phantom pain. 2. A well-balanced diet promotes wound healing, especially a diet high in protein. 3. The client must keep appointments in outpatient rehabilitation to continue to improve physically and emotionally. 4. A support group may help the client adjust to life with an amputation. 5. The client should be encouraged to get out as much as possible and live as normal a life as possible. TEST-TAKING HINT: The test taker needs to select all appropriate options.

42. The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client? 1. "Have you made any special arrangements for your amputated limb?" 2. "What types of food would you like to eat while you're in the hospital?" 3. "Would you like a rabbi to visit you while you are in the recovery room?" 4. "Will you start checking your other foot at least once a day for cuts?"

1. The Jewish faith believes all body parts must be buried together. Therefore, many synagogues will keep amputated limbs until death occurs. 2. Specific foods are important, but not while the client is in the operating room. 3. Spiritual issues are important for the nurse to discuss with the client, but the operating room should be concerned with disposition of the amputated limb. 4. Addressing teaching issues is important, but the most important concern is disposition of the amputated limb. TEST-TAKING HINT: The nurse must always address the cultural needs of the client, and when the test taker sees a specific culture in the stem of a question, it is a prompt indicating this will be important when selecting the answer.

44. The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? 1. Notify the client's surgeon immediately. 2. Assess the client's blood pressure and pulse. 3. Reinforce the dressing with additional dressing. 4. Check the client's last hemoglobin and hematocrit level.

2. Determining if the client is hemorrhaging is the first intervention. The nurse should check for signs of hypovolemic shock: decreased BP and increased pulse. 1. If the client is hemorrhaging, the surgeon needs to be notified, but hemorrhaging has not been determined. 3. Reinforcing the dressing helps decrease bleeding, but the nurse must assess first. 4. Checking the client's laboratory results is an appropriate intervention, but it is not the first intervention. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be probable interventions but only one is the first intervention. Also, the nurse should always assess first. Remember the nursing process.

47. The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation? 1. "I am going to sue the guy who hit my boat." 2. "The therapist is going to help me get retrained for another job." 3. "I decided not to get a prosthesis. I don't think I need it." 4. "My wife is so worried about me and I wish she weren't."

2. Looking toward the future and problem-solving indicate the client is accepting the loss. 1. This statement does not indicate acceptance; the client is still in the anger stage of grieving. 3. At this young age, a client with an upper extremity prosthesis needs to be thinking about obtaining employment and living a full life. Getting a prosthesis is important to pursue this goal. 4. This statement does not indicate acceptance; his wife will worry about the client's life, which has been changed dramatically. TEST-TAKING HINT: Always notice when the age is given for the client. This will help guide the test taker to the correct answer.

43. The client is three hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? 1. Explain to the client his left leg has been amputated. 2. Medicate the client with a narcotic analgesic immediately. 3. Instruct the client on how to perform biofeedback exercises. 4. Place the client's residual limb in the dependent position.

2. Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, and the nurse needs to medicate the client immediately. 1. The client is three hours postoperative and needs medical intervention. 3. Biofeedback exercises will not help address the client's postoperative surgical pain. 4. Placing the residual limb below the heart (dependent) will not help address the client's pain and could actually increase the pain. TEST-TAKING HINT: The test taker needs to be aware of adjectives such as "dependent." The nurse must know medical terms for positioning a client.

37. The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? 1. "This position will help your lungs expand better." 2. "Lying on your stomach will help prevent contractures." 3. "Many times this will help decrease pain in the limb." 4. "The position will take pressure off your backside."

2. The prone position will help stretch the hamstring muscles, which will help prevent flexion contractures leading to problems when fitting the client for a prosthesis. 1. This position will decrease lung expansion. 3. Lying on the back will not help decrease actual or phantom pain. 4. This will help take pressure off the client's buttocks area, but it is not why it is recommended for a client with a lower extremity amputation. TEST-TAKING HINT: The test taker can eliminate option "1" if visualizing the client in a prone position. This position will limit expansion of the lung more than increase it. When trying to allow for expansion of the lungs, clients are placed with the head elevated, a position the client in a prone position cannot achieve.

40. The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the friend to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the friend's house and call 911.

3. Applying direct pressure to the artery above the amputated parts will help decrease the bleeding immediately and is the first intervention the nurse should implement. Then the nurse should instruct the client to hold the hand above the head, apply towels, and call 911. 1. Wrapping the hand with towels is appropriate, but it is not the first intervention. 2. Holding the arm above the head will help decrease the bleeding, but it is not the first intervention. 4. Calling 911 should be done, but it is not the first intervention. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be probable interventions, but only one is the first intervention.

38. The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

3. The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally. 1. The client is in the recovery room, and the dressing must be assessed more frequently than every two hours. 2. The client must come to terms with the amputation; therefore, the nurse should encourage the client to look at the residual limb. 4. The nurse should encourage active, not passive, range-of-motion exercises. TEST-TAKING HINT: Remember to look at the phrases describing the intervention, such as "every two hours" and "passive."

41. A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? 1. Place the right thumb directly on some ice. 2. Put the right thumb in a glass of warm water. 3. Wrap the thumb in a clean piece of material. 4. Secure the thumb in a plastic bag and place on ice.

4. Placing the thumb in a plastic bag will protect it and then placing the plastic bag on ice will help preserve the thumb so it may be reconnected in surgery. Do not place the amputated part directly on ice because this will cause necrosis of viable tissue. 1. Placing the amputated part directly on ice will cause vasoconstriction and necrosis of viable tissue. 2. Warm water will cause the amputated part to disintegrate and lose viable tissue. 3. Wrapping the amputated part in a piece of material will not help preserve the thumb so it can be reconnected. TEST-TAKING HINT: The test taker should make sure he or she knows what the question is asking before selecting the option. The question is asking "what will help preserve the thumb?"—which is the key to answering this question.

45. The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Help the client with a 2-day postop amputation put on the prosthesis. 2. Request the UAP double-check a unit of blood to be hung. 3. Change the surgical dressing on the client with a Syme's amputation. 4. Ask the UAP to take the client to the physical therapy department.

4. The unlicensed assistive personnel (UAP) could take a client to another department in the hospital. 1. A client who is only two days postoperative amputation is not putting on a prosthesis. 2. Two registered nurses must double-check a unit of blood prior to infusing the blood. 3. The surgical dressing is changed by the surgeon or the nurse; Syme's amputation is above the ankle, just removing the foot. TEST-TAKING HINT: Remember teaching, assessing, and evaluating cannot be delegated.