The nurse is planning care for a patient who had an above-the-knee amputation 2 days ago. Which position should the nurse include in this patient's plan of care?
1. Sims' position as tolerated
2. Flat in bed
3. High Fowler's position with the stump elevated
4. Sitting in a chair while awake
2
Rationale 1: Sims' position is side-lying and would likely be uncomfortable for the patient.
Rationale 2: Lying flat in bed keeps the hip extended, which helps to prevent contracture.
Rationale 3: After 24 hours, the stump should not be elevated.
Rationale 4: Sitting in a chair for prolonged periods can lead to hip contracture.
You might also like to view...
Which behavior would the nurse evaluate as indicating successful completion of a bereaved
individual's grieving process? a. After 15 months, the widow realistically remembers both the pleasures and disappointments of her relationship with her husband. b. Three years after her husband's death, the widow talks about her husband as if he were alive, then weeps when others mention his name. c. For 2 years after her husband's death, the widow has kept his belongings in their usual places. d. Eighteen months after her husband's death, the widow states she has never cried or experienced feelings of loss even though they were very close.
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition
Which of the following will the nurse report? Select all that apply. A) A decreased respiratory rate B) Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 C) Nasal flaring with abdominal retractions D) Administration of a corticosteroid inhaler for quick relief E) Lung sounds of stridor F) Increased respiratory effort
The nurse realizes the patient is describing tolerance when the patient states:
1. "I seem to need an increasing amount of alcohol each evening just to unwind.". 2. "I think I have the flu. My stomach is upset and my hands are shaking.". 3. "If I have my drink before I go home, I don't lose my patience so easily.". 4. "I had a really good time at the party. At least my friends told me I did, but I don't remember much of it.".
A child has bronze-colored jaundiced skin. Which disorder should the nurse suspect this child is experiencing?
A) Hemophilia B) Sickle cell disease C) Kawasaki disease D) Thalassemia