A nurse is caring for a client who is 1 day postoperative following a below-the-knee amputation. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action the nurse should take is to place the client in a prone position for 30 minutes four times a day. This position helps prevent contractures after an amputation by stretching the hip flexors and preventing shortening of the residual limb. Keeping the residual limb flat on the bed (Choice A) may lead to contractures. Elevating the residual limb on a pillow (Choice B) can also cause contractures and hinder proper healing. Keeping the residual limb dependent (Choice D) is not recommended as it does not promote proper positioning and circulation.

Correct Answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

Correct Answer: C

Rationale: In this scenario, option C, elevating the head of the bed to 45 degrees, is the most appropriate intervention for a client at risk for developing pressure ulcers. This position helps reduce pressure on the sacrum and heels, two common sites for pressure ulcers. By elevating the head of the bed, the client's weight is distributed more evenly, decreasing the risk of tissue ischemia and pressure ulcer formation. Option A, using a donut-shaped cushion, is incorrect as it can actually increase pressure on vulnerable areas rather than distributing it evenly. This can exacerbate the risk of pressure ulcers rather than prevent them. Option B, turning the client every 4 hours, is a standard preventive measure for pressure ulcers, but it is not the most appropriate intervention in this specific case. Turning the client alone may not adequately alleviate pressure on specific areas prone to ulcers. Option D, massaging reddened areas, is contraindicated as it can further damage fragile skin and tissues, leading to the development or worsening of pressure ulcers. Educationally, it is important for nurses to understand the principles of pressure ulcer prevention and management. Proper positioning, regular repositioning, skin assessment, and pressure redistribution are key components of preventing pressure ulcers in at-risk individuals. Nurses should also be aware of individualized interventions based on the client's specific risk factors and needs to provide optimal care and prevent complications.

Correct Answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

Correct Answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.