Nursing Elites

1. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

2. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

• A. Encourage discussion about feelings of limb loss.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer assistance to move to a quiet room to relax.

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

3. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

• A. Wrap the stump with an elastic bandage to prevent swelling
• B. Keep the skin on the stump clean and dry
• C. Use alcohol to cleanse the stump daily
• D. Apply moisturizing lotion to the stump daily

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

4. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

• A. Candy for successful oral hygiene tasks.
• B. Tokens for each successful oral hygiene task.
• C. Privilege restrictions for refusing oral hygiene tasks.
• D. Preferred activities or privileges for compliance.

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

5. A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?

• A. Administer oxygen and elevate the head of the bed.
• B. Administer sublingual nitroglycerin as prescribed.
• C. Assess for signs of bleeding at the injection site.
• D. Administer a PRN dose of albuterol.

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.

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