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ANCC (RN-BC) Medical-Surgical Nursing 2024
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The nurse includes the important measures for stump care in the teaching plan for
a client with an amputation. Which measure would be excluded from the teaching plan?
Wash, dry, and inspect the stump daily
Treat superficial abrasions and blisters promptly
Apply a “shrinker” bandage with tighter arms around the proximal end of the affected limb
Toughen the stump by pushing it against a progressively harder substance (e.g., pillow on a foot-stool)
Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The “shrinker” bandage is applied to prevent swelling of the stump. It should be applied at the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow.
Which nursing action is the first priority during a generalized tonic-clonic seizure
episode?
Observe and record all events that occur before, during, and after the seizure
Maintain a patent airway by turning the head to the side
Protect the client from injury
Monitor vital signs, with special attention directed to respiratory status
The first priority is to protect the client from injury. Do not restrain the client’s arms or legs, but make sure he or she does not hit anything. Protect the head with the nurse’s hand, a towel, or a jacket. During the initial tonic phase, the client usually stops breathing for up to minute. There is no cause for alarm, as spontaneous breathing will, in most clients, return with no harm. In the absence of breathing, airway patency by this position change (Choice B) is not the first priority. Muscle contraction will prevent “positioning” of the head. A padded tongue blade, once indicated during a seizure, is also no longer used. Choices A and D are appropriate nursing actions after the seizure has ended.
Levin, age 27, was driving home when his car collided with another moving
vehicle. He obtained multiple injuries and a concussion. The paramedics placed a hard neck brace to immobilize the spine. Upon arriving at the hospital, X-rays are inconclusive because of swelling. To assess and care for the skin under the collar, the nurse should:
Place the client flat and supine; remove the anterior section of the collar, turning the head to the right or left to remove the back section.
Have the client sit up in a chair to remove the front and back sections without turning the head from side to side.
Have at least one nurse stabilize the head in line with the torso, while the other nurse removes the collar sections.
Wait until the X-rays are conclusive for any trauma before assessing the skin or providing skin care under the collar.
The head and neck are maintained in an aligned position at all times and supported. The collar is hard and can cause skin breakdown. The collar liner should be changed daily and the underlying skin cleansed. Turning the head from side to side may cause injury to the spine (Choice A). Choice B is incorrect because the client may be experiencing weakness and there is no support for the
neck if the collar is removed. The collar liner must be changed and the skin cleaned daily to prevent breakdown (Choice D). The presence or absence of a spinal injury may not be determined in less than 24 hours.
Troy, 27 years old, suffered from multiple injuries after his car crashed into a
moving vehicle. He was then rushed to a nearby hospital where his left leg was amputated below the knee. After surgery, the physician’s orders include elevation
of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under Troy’s amputated limb. The nursing action is to:
Leave the pillow, as his stump is elevated
Remove the pillow and elevate the foot of the bed
Leave the pillow and elevate the foot of the bed
Check with the physician and clarify the orders
The orders call for bed elevation (this is done to reduce edema and prevent hemorrhage). A pillow under the stump may lead to a flexion contracture of the hip joint, so this is contraindicated. Also, further teaching is indicated so that the nursing assistant understands why the pillow is contraindicated.
A client is scheduled for an electroencephalogram (EEG) early in the morning.
The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol order in the early morning on the day of the test?
Instruct the client to refrain from washing the hair
Hold the daily dose of anticonvulsant
Place the client on NPO status
Reinforce client teaching that the test is only mildly uncomfortable
Antidepressants, tranquilizers, and anticonvulsants are generally withheld for 24 to 48 hours before an EEG. The client does not have to be on NPO, but should avoid stimulants such as coffee, tea, cola, alcohol, and cigarettes. Pre-procedure care for EEG involves teaching that there is no discomfort and shampooing the hair.
S. McCormick, R.N., is one of several persons who witness a vehicle hit a
pedestrian at fairly low speed on a street. The person is dazed and tries to get up. The leg appears fractured. Ms. McCormick would plan to:
Try to reduce the fracture manually
Assist the person to get up and walk to the sidewalk
Leave the person for a few moments to call an ambulance
Stay with the person and encourage the person to remain still
With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. A fracture is not reduced at the scene (Choice A). Choice B is incorrect because before the client is moved, the site of fracture is immobilized to prevent further injury. Choice C is incorrect because the nurse should remain with client and have someone else call for emergency help.