MED-SURG CH. 45 EAQ QUESTIONS

Which action by the patient indicates the need for additional teaching about caring for his or her residual limb and prosthesis? 1. Application of powder 2. Keeping the residual limb socket dry 3. Removing the prosthetic upon irritation 4. Washing the residual limb with soap and water daily

1. Application of powder Lotions, creams, and talcum powder should be avoided unless suggested by the physician because they may create abrasions. Bacterial and fungal infections can be prevented by keeping the residual limb socket clean and dry. The patient should remove the prosthetic temporarily if any irritation or redness is evident to prevent ulceration and further complications. Washing the residual limb with soap and water daily helps to reduce the chance of infection.

Which statement by the patient who has undergone replantation surgery indicates the need for further education about necessary interventions? 1. "I should avoid taking aspirin." 2. "I should avoid caffeine for a few days." 3. "I should wear a loose gown or pajamas." 4. "I should elevate the limb at the heart level."

1. "I should avoid taking aspirin." Aspirin is necessary to reduce the risk of venous thrombosis, so the patient should take aspirin as prescribed by the primary health care provider. Caffeine and nicotine products aggravate the injury or risk for infection and should be completely avoided after surgery. Loose gowns and pajamas prevent coagulation and ensure that the patient is comfortable. Elevating the limb helps to reduce edema, and keeping the limb at heart level ensures that the blood does not flow back to the heart.

The LPN is caring for a patient who has undergone arteriography. Which is the priority postprocedural nursing action? 1. Maintain pressure dressing. 2. Administer pain medication. 3. Encourage increased fluid intake. 4. Assess the patient's level of anxiety.

1. Maintain pressure dressing. The nurse would maintain the pressure dressing to prevent the development of hemorrhage and hematoma from the site; prevention of hemorrhage is the most important nursing intervention. Additionally, the patient should be kept as comfortable as possible, fluids should be increased to encourage excretion of the contrast medium, and the patient's anxiety level should be kept to a manageable level.

The LPN is caring for a postoperative patient who had a surgical amputation. Which aspect of care is considered the priority in the early postoperative period? 1. Monitor vital signs for changes. 2. Verify that the wound is healing. 3. Restore the patient's physical mobility. 4. Clarify changes in the patient's self-image.

1. Monitor vital signs for changes. Monitoring vital signs is a priority because of the risk for hemorrhage and decreased cardiac output. Although verifying that the wound is healing and confirming that no evidence of infection is present are both important, monitoring vital signs that might prevent complications that could develop is the more immediate concern. Restoration of the patient's physical mobility and clarification of changes in the patient's self-image will become important later in the postoperative period after the patient's condition has stabilized.

Which complication of amputation requires surgical debridement? 1. Necrosis 2. Gangrene 3. Hematoma 4. Wound dehiscence

1. Necrosis Necrosis is tissue destruction and death. It requires surgical debridement of the necrotized tissue. Inadequate blood supply and bacterial destruction of tissue cause the death of healthy tissue and gangrene formation. Hematoma is bleeding into the tissue in and around the residual limb. Wound dehiscence is opening of the suture line due to early removal of the sutures. Reclosure is beneficial in a patient who has wound dehiscence.

The nurse is assessing a patient with an above-the-knee amputation during the early postoperative period for complications. The nurse should understand that the patient is at risk for what complications? Select all that apply. 1. Pain 2. Edema 3. Dysuria 4. Infection 5. Leukopenia 6. Hemorrhage

1. Pain 2. Edema 4. Infection 6. Hemorrhage The most common problems in the early postoperative period for patients with amputations are hemorrhage, edema, infection, and pain. If infection were present, the patient would have an elevated WBC (leukocytosis), not a decreased WBC (leukopenia). Dysuria would not be associated with amputations.

A patient with arterial thrombosis has obstruction of blood vessels that resulted in amputation of the leg. The nurse suspects that the patient is developing an infection related to the wound. Which finding helped the nurse to reach this conclusion? Select all that apply. 1. The patient's heart rate is 80 beats per minute. 2. The patient's body temperature is 102°F (38.8°C). 3. The patient has warmth and edema in the residual limb. 4. The patient has a wet dressing that appears yellow and has an odor. 5. The patient has the sensation of a phantom limb associated with pain.

2. The patient's body temperature is 102°F (38.8°C). 3. The patient has warmth and edema in the residual limb. 4. The patient has a wet dressing that appears yellow and has an odor. The patient has undergone amputation and has risk of infection. The normal body temperature is 98.6°F (37°C). An increase in body temperature to 100°F (37.7°C) indicates an infection. The patient has warmth and edema in the residual limb, possibly indicating an infection. The foul-smelling dressing indicates an infection. The normal heart rate is 60 to 100 beats per minute. The patient has a heart rate of 80 beats per minute, which does not indicate infection. Phantom limb sensation is a normal finding a few days after surgery and does not indicate infection.

A patient has had a bilateral below-the-knee amputation as a result of a work-related explosion. The patient has been discharged to an inpatient rehabilitation center to learn how to function without his legs. In order for the patient to transfer safely, what exercises should the physical therapist include in the patient's care? 1. Leg lifts 2. Arm swings 3. Arm presses 4. Chest thrusts

3. Arm presses After lower extremity amputation, safe mobility is a priority. The patient should be encouraged to do exercises that strengthen his upper extremities. In order for a patient with a double amputation to transfer safely, he/she must possess upper body strength. This is accomplished by having the patient complete arm presses while seated. The other options do not promote increased arm strength.

The nurse is teaching a patient with a recent below-the-knee amputation. What should the nurse include in the teaching plan? 1. The patient should wear the prosthesis at all times. 2. The patient should wash and dry the residual limb every other day. 3. The patient should wash and dry the socket of the prosthesis before use. 4. The patient should wash the socket of the prosthesis with Phisoderm every week.

3. The patient should wash and dry the socket of the prosthesis before use. The prosthesis socket should be cleaned with soap and water and dried thoroughly before use. The patient should wash and dry the residual limb with soap and water every day. Phisoderm is not needed; soap and water is sufficient. The prosthesis should be removed at bedtime and periodically throughout the day to assess for pressure points.

A patient who has undergone amputation of the right leg has a body temperature of 39°C, and the residual limb is red, warm, and edematous. Which laboratory test does the nurse expect to be ordered? 1. Bone biopsy 2. Arteriography 3. Plethysmography 4. White blood cell count

4. White blood cell count An elevated body temperature, redness, and swelling of the residual limb are signs of infection. An elevated white blood cell count in the presence of infection would help to confirm the infection of the residual limb. A bone biopsy is not indicated by the symptoms of elevated body temperature, redness, and swelling of the residual limb. Arteriography is used to detect any arterial occlusion and is indicated in patients with peripheral vascular disease to assess circulation. Plethysmography, also called pulse oximetry, is used to evaluate the arterial blood flow to the extremities.

The nurse is assessing the capillary refill of a patient who has a cast on his left foot and determines that the capillary refill time is 2 seconds. What is the nurse's priority action? 1. Document the findings. 2. No further action is necessary. 3. Notify the health care provider. 4. Massage the patient's toes to increase blood flow.

1. Document the findings. Capillary refill is determined by applying pressure to the nail bed of a finger or toe until it blanches (turns white). When the pressure is released, the nail bed normally regains its normal pink color within 3 seconds. In extremities with a diminished supply of blood, capillary refill may take 5 seconds or longer. The nurse would document the findings in the patient's medical record because this is a normal finding. It is not necessary to notify the health care provider of this normal finding unless the health care provider has expressed a desire to know the results of the capillary refill test. Doing nothing is not appropriate because if the results of the capillary refill test are not in the chart, then there is no permanent record of the nurse performing the assessment. Blood flow to the patient's toes is adequate as evidenced by a normal capillary refill time; if the capillary refill time was greater than 3 seconds, the nurse would not massage the patient's toes without first knowing the cause of the decreased blood flow.

A patient has returned to the nursing unit after replantation of the right thumb. What should be included in priority assessments by the nurse? Select all that apply. 1. Presence of pulsations via Doppler 2. Vital signs and level of consciousness 3. Presence or absence of the gag reflex 4. Ability to feel pressure in the right thumb 5. Ability to extend the right shoulder and elbow 6. Less than 3-second capillary refill of the thumb

1. Presence of pulsations via Doppler 2. Vital signs and level of consciousness 4. Ability to feel pressure in the right thumb 6. Less than 3-second capillary refill of the thumb Postoperative assessment includes monitoring vital signs and level of consciousness. A neurovascular assessment is also important at this time. It is not the priority to assess for movement of the shoulder and elbow or to assess the gag reflex.

The nurse finds that a patient who has undergone amputation of an arm has an elevated body temperature, redness, warmth, and exudate formation at the site of the wound. Further examination reveals necrosis at the amputated area. Which intervention does the nurse suspect to be beneficial in this patient for safe and effective care? 1. Reamputation 2. Sympathectomy 3. Surgical debridement 4. Reclosure of the wound

1. Reamputation An elevated body temperature, redness, warmth, and exudate formation indicates infection. Necrosis resulting from bacterial destruction is called gangrene, which requires reamputation to prevent the spread of infection. Sympathectomy is a treatment approach used to reduce pain. Surgical debridement is indicated for necrosis. Reclosure of the wound is indicated if the patient has wound dehiscence.

Radiographic examination of a patient who has undergone an amputation indicates that lesions are present at the site of surgery. The primary health care provider has instructed the nurse to obtain signed consent for further examination and treatment. What could be the reason for this action? 1. The patient is scheduled for a biopsy. 2. The patient is undergoing a blood test. 3. The patient is undergoing plethysmography. 4. The patient is scheduled for Doppler ultrasound.

1. The patient is scheduled for a biopsy. A biopsy is a procedure in which a bone sample is taken surgically and examined for the presence of lesions. Biopsy is an invasive procedure, so the patient is asked to sign the consent form. The patient has lesions at the site of surgery, which are a sign of cancer. A blood test will help to assess the white blood cell count and the presence of infection. However, a consent form is not required to perform a blood test. Plethysmography is a device that helps to assess the pulse volume reading and arterial blood flow and does not require a consent form. Doppler ultrasound examination is helpful to assess the patency of the blood vessels after amputation, but it does not require a consent form.

Which finding helped the nurse to conclude that a patient has a diminished blood supply to the extremities? 1. The patient's capillary refill time is 5 seconds. 2. The patient's blood pressure is 125/85 mm Hg. 3. The patient's pulse rate is 70 beats per minute. 4. The patient's body temperature is 98.4°F (37°C).

1. The patient's capillary refill time is 5 seconds. The capillary refill time is the time taken by the nail bed to resume its normal color after blanching. The normal time required is 3 seconds; however, the patient has a capillary refill time of 5 seconds, indicating a diminished blood supply. The patient's blood pressure is 125/85 mm Hg, which is within normal range. The patient has a heart rate of 70 beats per minute, which is normal. A normal body temperature is 98.4°F (37°C), which is the patient's body temperature.

A patient is undergoing a complete physical examination prior to undergoing an amputation of the right leg. The health care provider conducting the integumentary assessment should focus on which specific areas? Select all that apply. 1. Turgor 2. Texture 3. Skin color 4. Temperature 5. Senses (touch, smell, sight, hear, taste)

1. Turgor 2. Texture 3. Skin color 4. Temperature A total physical exam should be performed, with special attention to the neurological, cardiovascular, and integumentary systems. This question specifically asks about the integumentary aspect of the exam. The health care provider would record the patient's turgor, texture, skin color, and temperature. The senses are assessed during the neurological assessment.

While caring for a patient who has undergone an amputation, the nurse observes that the patient has skin disintegration. Which intervention will be beneficial for the patient? 1. Using "shrinker socks" at the site 2. Applying the bandage like a tourniquet 3. Elevating the extremity above heart level 4. Placing the patient in a high Fowler position

1. Using "shrinker socks" at the site Shrinker socks will help to bind the residual limb moderately and reduce the risk of edema, which will maintain skin integrity appropriately. The bandage should not be too tight or like a tourniquet because it may cause injury to the residual limb and reduce blood flow. Elevating the extremity above heart level increases the risk of backflow of blood to the heart. Placing the patient in a high Fowler position may result in contracture of the hip.

The nurse is caring for a patient who has undergone an amputation of the leg. The nurse finds that the patient prefers to sit for long periods. Which is the nurse's best response? 1. "Your injury will take less time to heal if you sit for long periods." 2. "You may develop hip or knee contracture if you sit for long periods." 3. "You will be able to administer self-care more quickly if you sit for long periods." 4. "You will not feel any phantom limb sensation if you refrain from sitting for long periods."

2. "You may develop hip or knee contracture if you sit for long periods." The patient has undergone an amputation; therefore, sitting for a prolonged time may result in knee or hip contracture because the pressure on the knee and hip is increased. Sitting for long periods will prolong the process of healing. A patient who has improved healing will be able to handle self-care faster. The sensation of a phantom limb does not depend on the patient's position because it is a perception.

The nurse is caring for a patient who recently underwent surgery to amputate the left leg below the knee and is preparing for the creation of a prosthesis. The nurse knows that a suitable choice for a prosthesis is based on which factors? Select all that apply. 1. Sex 2. Age 3. Motivation 4. Intelligence 5. Health status 6. Financial status

2. Age 3. Motivation 4. Intelligence 5. Health status 6. Financial status A suitable choice for a prosthesis is based on the site of the amputation and the age, motivation, intelligence, health status, financial status, and occupation of the patient. The sex of the patient is not a consideration for choice of prosthesis.

The nurse is assessing a patient 24 hours after an above-the-knee amputation and finds bright red blood on the bed, under the patient's thigh. Place the immediate nursing interventions for this patient in order of priority. 1. Elevate the residual limb. 2. Apply pressure to the site. 3. Notify the health care provider. 4. Assess the patient's vital signs.

2. Apply pressure to the site. 1. Elevate the residual limb. 4. Assess the patient's vital signs. 3. Notify the health care provider. If bright red bleeding is found on the dressing or in the patient's bed, the nurse should first apply pressure (either another pressure dressing or direct pressure) and then elevate the residual limb. The nurse should summon assistance, assess vital signs, and have someone call the health care provider.

The nurse is assessing the compression dressing for a patient 4 hours after a below-the-knee amputation for bleeding. A small amount of drainage is noted on the dressing. The nurse correctly documents which nursing actionsto address the drainage? 1. Changing the dressing 2. Circling the drainage with a pen 3. Reinforcing the dressing with Kerlix 4. Removing and discarding the dressing, and then leaving the wound to air

2. Circling the drainage with a pen If drainage is noted on the compression dressing, the nurse should circle the drainage with a pen and then document it in the patient's chart. The nurse only reinforces the dressing in the event that the dressing has come off or has loosened. The dressing is only changed if it is saturated. The amputation is only 4 hours old; therefore leaving it to air is not conducive to healing.

A patient has returned to the nursing unit after replantation of the right great toe. The nurse should perform a neurovascular assessment of the replanted digit. Which assessment finding would concern the nurse the most? 1. Color is pink 2. Cold to touch 3. Warm to touch 4. Capillary refill is 3 seconds

2. Cold to touch A digit that has been replanted should have adequate blood supply, which would cause it to feel warm. If the digit feels cold to touch, especially when compared to the left great toe, this indicates inadequate blood flow to the replanted toe. The health care provider should be notified immediately and the patient prepared to return to surgery. A capillary refill of 3 seconds is within normal limits.

The patient tells the LPN that he feels nauseated after being injected with contrast medium for arteriography. Which is the priority nursing action? 1. Document the symptom; this response to the contrast is unexpected. 2. Continue to monitor the patient; this response to the contrast is expected. 3. Notify the health care provider that the patient shows signs of an anaphylactic reaction. 4. Notify the health care provider that the patient has received an excessive amount of contrast.

2. Continue to monitor the patient; this response to the contrast is expected. The patient may experience a flushed feeling or nausea in response to the contrast medium. Nausea is an expected response to the contrast medium, not evidence that the patient has received too much contrast medium or of an anaphylactic reaction.

The nurse is assessing the closed incision site of a patient 48 hours after a below-the-knee amputation for signs and symptoms of infection. Which assessment finding would concern the nurse? Select all that apply. 1. Warm, pink stump 2. Foul odor from dressing 3. Swollen and red residual limb 4. Sudden temperature elevation 5. Elevated white blood cell count 6. Scant amount of blood-tinged drainage on dressing

2. Foul odor from dressing 3. Swollen and red residual limb 4. Sudden temperature elevation 5. Elevated white blood cell count A foul odor, swollen and red stump, sudden elevation in temperature, and elevated white blood cell count would indicate a possible infection and need to be reported to the health care provider. A warm and pink stump is a normal finding, as well as a scant amount of blood-tinged drainage on the dressing.

Which signs indicate decreased cardiac output in a patient who has undergone an amputation? Select all that apply. 1. Edema 2. Hypotension 3. Increased pulse 4. Increased temperature 5. Increased respiratory rate

2. Hypotension 3. Increased pulse 5. Increased respiratory rate Decreased cardiac output in a patient who has undergone amputation is caused by excessive bleeding or hemorrhage. Hypotension and cyanosis are late signs of hemorrhage; whereas, increasing pulse and respiratory rate are early signs of hemorrhage. Increased temperature indicates development of infection. Edema may occur due to incorrect wrapping of the residual limb.

Which diagnostic test is used to palpate the peripheral pulses? 1. Arteriography 2. Thermography 3. Doppler ultrasound 4. Pulse volume recording

3. Doppler ultrasound Doppler ultrasound uses sound waves to determine the presence of pulses in the extremities. Arteriography helps to detect arterial occlusion. Thermography is useful in detecting and recording heat in various parts of the body, which is indicative of the amount of blood flow to that part of the body. Pulse volume recording, also called plethysmography, is used to evaluate the arterial blood flow to the extremities.

A patient is scheduled to have an arteriography after a severe injury to the left leg. What should the nurse include in the pretest care and teaching for this patient? Select all that apply. 1. NPO for at least 24 hours prior to test. 2. Inquire about iodine or shellfish allergies. 3. Patient should have a full bladder for this test. 4. Peripheral pulses should be marked prior to test. 5. Patient may feel flushed or nauseated with injection of dye. 6. Considered an invasive procedure; therefore consent form needed.

2. Inquire about iodine or shellfish allergies. 4. Peripheral pulses should be marked prior to test. 5. Patient may feel flushed or nauseated with injection of dye. 6. Considered an invasive procedure; therefore consent form needed. Inquire about allergy to contrast medium, iodine, or shellfish, prior to test and inform radiologist if allergy exists. The patient should be NPO for 8 hours prior to the test and a consent form should be signed by the patient. Baseline peripheral pulses should be assessed and marked prior to test. The patient should empty his/her bladder just prior to the test.

After amputation surgery, the interdisciplinary team works to increase the patient's functional ability and mobility. Which discipline is usually charged with initiating an exercise program? 1. Nurse 2. Physical therapist 3. Health care provider 4. Occupational therapist

2. Physical therapist The physical therapist usually initiates an exercise program. An important goal is the prevention of contractures. The health care provider will order a consultation by physical therapy, and the nurse will reinforce the teaching by the physical therapist, but the physical therapist performs the assessment and creates an individual plan for the patient. The occupational therapist works with the patient to increase the patient's functional ability.

The nurse is teaching a patient to apply a compression dressing to the residual limb. If the patient asks about the purpose of the compression dressing, what would be the best response by the nurse? 1. "The compression dressing is applied to increase the chance of hemorrhage." 2. "The compression dressing is used to delay healing, which enhances healing from the inside out." 3. "The compression dressing is used to promote healing and to help shrink and taper the residual limb." 4. "The compression dressing serves as a tourniquet to decrease the amount of blood flow to the suture line."

3. "The compression dressing is used to promote healing and to help shrink and taper the residual limb." The residual limb is bandaged to promote healing and to shrink and shape the residual limb to a tapered, round, smooth end that will fit the prosthesis. A compression dressing should decrease, not increase, the chance of hemorrhage. Blood supply should not be decreased with the use of a compression dressing. The compression dressing does not delay healing so that the wound can heal by secondary intention.

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 is the best response of the nurse? 1. "You may have an infection; you will need antibiotics." 2. "You should consult a psychiatrist before it gets severe." 3. "This feeling will likely go away soon after you start moving." 4. "I think you should consult the doctor and stop your medications for a few days."

3. "This feeling will likely go away soon after you start moving." The patient has severe pain in the amputated arm with a strange sensation, indicating that the patient has a phantom limb sensation. The feelings will cease after several days when the patient starts movement. A patient with infection will have edema, redness, fever, and foul-smelling discharge. There is no reason to consult a psychiatrist due to the phantom limb sensation. Phantom limb sensation is not caused by any side effects of medication; therefore, the nurse would not instruct the patient to consult the doctor and stop medication.

A nurse is caring for multiple patients with above-the-knee amputations. Which patient would the nurse assess first? 1. A patient who refuses to move the leg at all. 2. A patient with pain rated 4 on scale of 1 to 10. 3. A patient who complains of phantom limb pain. 4. A patient who complains of constipation and gas discomfort.

3. A patient who complains of phantom limb pain. It is important to gain control of phantom limb pain as soon as possible. This type of pain is harder to control once it begins. The patient may be refusing to move the leg because he or she may believe that it will cause pain; therefore it is not a priority over phantom limb pain. A pain rating of 4 is not a priority at this time; however it should not be ignored altogether. Constipation and gas discomfort are not a priority over phantom limb pain.

The licensed practical nurse (LPN) is contributing to data collection by assisting with completing a health history for a patient who had a foot amputated 5 years ago. Which would be the first piece of information the nurse would collect on the patient? 1. How the patient copes when faced with stress. 2. Relevant family disorders such as hypertension. 3. Conditions that resulted in the need for an amputation. 4. Diet and fluid intake and the use of salt, alcohol, and tobacco.

3. Conditions that resulted in the need for an amputation. Recording the conditions that resulted in the need for an amputation (e.g., diabetes mellitus, peripheral vascular insufficiency, traumatic injuries, neoplasms, birth defects) is the initial piece of information that the nurse should include in the health history. How the patient copes when faced with stress is important information, but it is not part of the health history. A relevant family disorder, such as hypertension, is important information, but family history would not be the priority that the patient's own health conditions would be. Diet and fluid intake, as well as the use of salt, alcohol, and tobacco, would be included in the functional assessment, not in the health history.

The nurse is caring for a patient who has just returned from the postanesthesia care unit following amputation surgery. About which complication would the nurse be most concerned? 1. Injury 2. Infection 3. Hemorrhage 4. Poor pain management

3. Hemorrhage Hemorrhage is the greatest danger in the early postoperative period of amputation surgery. The risk for injury increases as the patient begins rehabilitation. Infection becomes a concern several days after the operation. Poor pain management is an issue throughout the postoperative period, but it is not the most life-threatening.

A patient returns to the medical/surgical unit following a replantation of the left arm. Which nursing intervention(s) would be appropriate for this patient? Select all that apply. 1. Elevate the limb above the level of the heart. 2. Allow the patient to smoke three times a day. 3. Keep the patient's room temperature at 80º F. 4. Ensure patient's pajamas and/or gown is nonconstrictive. 5. Elevate limb but not above the level of the heart.

3. Keep the patient's room temperature at 80º F. 4. Ensure patient's pajamas and/or gown is nonconstrictive. 5. Elevate limb but not above the level of the heart. Measures to promote circulation to the replanted limb include elevation of the limb; however do not elevate above the level of the heart as this may impair arterial flow. Elevate the limb on a single pillow to promote venous return and lymphatic drainage. The patient should not smoke or consume products with caffeine as these are vasoconstriction agents. Loosen all tight clothing to prevent circulatory problems. The nurse should prevent the patient from becoming chilled, as shivering causes metabolic acidosis and vasoconstriction.

A prosthetist is instructing a patient on the use of a lower limb prosthesis. The patient asks when he will be able to bear full weight on a permanent prosthesis. Which reply from the prosthetist would be correct? The prosthetist replies, "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis in approximately which time frame after amputation." 1. "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis within two weeks after amputation." 2. "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis within four weeks after amputation." 3. "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis within two months after amputation." 4. "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis within three months after amputation."

4. "Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis within three months after amputation." Providing that no problems arise, a patient can usually bear full weight on a permanent prosthesis in approximately 3 months after amputation. Any amount of time less than 3 months may not be enough for the patient's residual limb to tolerate full weight-bearing.

A patient required an above-the-knee amputation for a crush injury to the lower-left leg. Twenty-four hours postoperatively, the patient is complaining that his left foot is itching and asks why this is happening. What would be the best response by the nurse? 1. "The itching occurs because you are experiencing phantom limb pain." 2. "You should talk with your doctor about this because this is abnormal." 3. "You are having this sensation because the nerve endings are still intact in the left foot." 4. "You are experiencing phantom limb sensation, which is a completely normal response after amputation."

4. "You are experiencing phantom limb sensation, which is a completely normal response after amputation." Patients experience sensations such as tingling, numbness, itching, and warmth/cold as if the limb is still present. These sensations are caused by stimulation along the nerve pathway in which the sensory endings were in the amputated part. The nerve endings are no longer intact, because the limb has been amputated. Just mentioning that the patient has phantom limb pain and that's what is causing the itching is not a complete enough answer. The patient must be assured that it is completely normal. Phantom limb sensation is an expected occurrence with amputations and is not considered an abnormal finding.

The nurse is assessing a patient with a recent below-the knee amputation for complications. What complication should the nurse consider the most concerning? 1. Pain at the incision site. 2. Redness at the incision site. 3. Slight swelling at and around the staples. 4. Dressing saturated with bright red blood.

4. Dressing saturated with bright red blood. Hemorrhage is the greatest danger in the early postoperative period. Bright red bleeding from the site is not normal, and the health care provider should be notified immediately. Pain, redness, and slight swelling at the incision site are a common occurrence and would not be considered the most concerning complication.

While monitoring a patient who has undergone an amputation, the nurse finds a blood pressure of 96/64 mmHg and bluish discoloration of the skin. Which complication does the nurse suspect? 1. Edema 2. Infection 3. Contracture 4. Hemorrhage

4. Hemorrhage A blood pressure of 96/64 mmHg and bluish discoloration of the skin indicates hypotension and cyanosis, which are late signs of hemorrhage in a patient who has undergone amputation. Edema presents as swelling and discomfort in the residual limb. Redness, warmth, swelling, temperature elevation, and exudate formation at the residual limb site indicate infection. Contracture is the flexion of joints with loss of range of motion because of prolonged elevation or immobilization of the extremities.

An older adult patient recently had an above-the-knee amputation, and the nurse is teaching about the healing process. Which diet would be best to meet the patient's needs at this time pending no additional health problems? 1. 2 gram Na 2. High-fat high-calorie 3. Low-fat low-carbohydrate 4. High-protein high-calorie

4. High-protein high-calorie Many older adults have a decreased appetite, and their nutritional status may be poor. Protein is the building block to healing, so a diet high in protein is encouraged. A high-calorie diet is also recommended as the patient needs to maintain or build up strength. The two-gram Na, high-fat high-calorie, and low-fat low-carbohydrate diets would not promote wound healing.

PATIENT A: The patient has obstruction of blood vessels due to a clot and is scheduled for surgical bypass. PATIENT B: The patient has amputation of an arm. The arm is uncovered for a few days and is sutured after the risk of infection is alleviated. PATIENT C: The patient has amputation of a leg, and an artificial substitute is placed after the residual limb is healed. PATIENT D: The patient has a leg amputation and a long skin flap with soft tissue and muscle positioned over the severed end of the bone and sutured in place. Which patient is undergoing a closed amputation treatment? 1. Patient A 2. Patient B 3. Patient C 4. Patient D

4. Patient D Patient D has a leg amputation and a long skin flap with soft tissue and muscle sutured over the bone, which indicates closed amputation treatment because a bone is sutured in place. Patient A has obstruction of blood vessels due to a clot and is scheduled for a surgical bypass, which indicates that the patient is undergoing surgical treatment but not a closed amputation treatment. Patient B has an amputation of the arm and the severed bone or joint is left uncovered by a skin flap, indicating that the patient is undergoing open amputation treatment. Patient C has an artificial substitute for the arm after amputation, indicating that the patient has prosthesis treatment.

A 27-year-old man has sustained an amputation in an industrial accident. Emergency care to increase the chance for replantation for this injury should include which factor? 1. Immediately applying a tourniquet 2. Placing the amputated parts directly in ice 3. Wrapping the amputated parts in a clean, dry cloth 4. Placing the amputated parts in a sealed plastic bag and then placing it in ice water

4. Placing the amputated parts in a sealed plastic bag and then placing it in ice water Proper handling of the amputated parts is extremely important for successful replantation. Current preservation techniques include wrapping the amputated parts in a clean cloth saturated with normal saline or lactated Ringer's solution. These parts are then placed in a sealed plastic bag and placed in ice water. Direct contact between the amputated parts and the ice can lead to further tissue damage and cell death. Tourniquets should not be used unless absolutely necessary, because they can cause ischemia of the residual limb.

A patient who is diabetic is hospitalized for a below-the-knee amputation. Due to the patient's history of diabetes, what would the nurse specifically assess for? 1. Edematous residual limb 2. Slight redness at the incision site 3. Slight bleeding at several staple sites 4. Separation of wound edges (dehiscence)

4. Separation of wound edges (dehiscence) Diabetes mellitus increases the patient's risk for infection and delayed wound healing time. Dehiscence of the wound edges is a sign of delayed wound healing and opens a portal of entry for organisms. Immediately postoperatively and several days thereafter, it is common for the incision site to be slightly red and edematous. This should dissipate as the wound heals. It is common for staple or suture sites to ooze a small amount of bloody drainage.

The nurse is caring for a patient with a left above the knee amputation. The patient is complaining of severe pain in the left leg and wants something for pain. What should the nurse do first? 1. Notify the surgeon. 2. Medicate the patient immediately. 3. Advise the patient that several therapies are available for the treatment of this problem. 4. Tell the patient that this is phantom limb pain and sometimes follows amputation.

4. Tell the patient that this is phantom limb pain and sometimes follows amputation. The nurse should first explain to the patient that this is phantom limb pain and sometimes follows amputation. The patient should be given pain medication afterwards. The surgeon should be notified if this is continuous. The patient should also be advised that there are several therapies available for the treatment of this problem.

A patient presents to the emergency department by ambulance after severing the left ring finger. The paramedics transport the severed finger with the patient. What is the most effective way to care for an amputated digit (finger) pending replantation? 1. Place it in a plastic bag, place it on ice, and transport it. 2. Wrap it in a clean, dry cloth, and transport it with the patient. 3. Place it directly on ice, and transport it separately from the patient. 4. Wrap it in a normal saline-saturated clean cloth, seal it in a plastic bag, place it in ice water, and transport it with the patient.

4. Wrap it in a normal saline-saturated clean cloth, seal it in a plastic bag, place it in ice water, and transport it with the patient. A severed body part that can be replanted should never be placed directly on ice due to the fragility of the blood vessels. The severed digit should be wrapped with a normal saline or a lactated Ringer's-saturated clean cloth, sealed in a plastic bag, placed in ice water, and transported with the patient.