The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take?

Correct Answer: B

Rationale: The correct answer is B because administering prescribed analgesics is the most important action to address the patient's pain. The pain experienced is known as phantom limb pain, which is common after amputations. Analgesics can help manage the pain effectively. Choice A is not as crucial as providing immediate pain relief. Choice C focuses on alignment rather than pain management. Choice D, while providing reassurance, does not address the immediate need for pain relief.

Correct Answer: A

Rationale: The correct answer is A: assess the surgical site for hemorrhage. After an above-the-knee amputation, assessing the surgical site for hemorrhage is crucial as it helps in early detection and management of any bleeding, which can be life-threatening. Other choices are incorrect: B is wrong as removing the prosthesis can disrupt wound healing; C is incorrect as it doesn't address the immediate post-op concern of hemorrhage; D is incorrect as keeping the residual limb elevated on a pillow may not be the priority over assessing for hemorrhage.

Correct Answer: C

Rationale: The correct answer is C: Check the patient’s O2 saturation using pulse oximetry. This is the first action the nurse should take because it directly assesses the patient's oxygen levels, which is crucial for determining the patient's immediate respiratory status and need for intervention. Monitoring oxygen saturation helps in identifying hypoxemia, which can be life-threatening and requires prompt attention. Administering morphine IV (choice A) could potentially worsen respiratory depression if the patient is already hypoxic. Contacting the operating room for surgery (choice B) is not appropriate without assessing the patient's oxygenation first. Asking about the date of the last tetanus immunization (choice D) is important but not the priority when the patient's oxygenation is in question.

Correct Answer: D

Rationale: The correct answer is D because wearing only sandals and avoiding closed-toe shoes will not effectively address the discomfort from the bunion. This response indicates a lack of understanding about proper footwear choices to reduce pressure on the bunion. Other choices (A, B, C) show actions that may actually help alleviate discomfort temporarily, like giving away high-heeled shoes, using a bunion pad, or taking ibuprofen. However, these choices do not address the root cause of the issue, which is pressure and friction on the bunion. Therefore, choice D is the correct answer as it highlights the need for further education on appropriate footwear to manage bunion discomfort effectively.

Correct Answer: C

Rationale: The correct answer is C because log rolling the patient from side to side every 2 hours is a task that can be safely delegated to experienced unlicensed assistive personnel (UAP). This task helps prevent complications such as pressure ulcers and promotes mobility without risking injury. A: Checking the ability to plantar and dorsiflex the foot requires clinical judgment and may indicate nerve damage, which should be assessed by a licensed nurse. B: Determining the patient's readiness to ambulate involves assessing strength, balance, and coordination, which requires nursing judgment and assessment skills. D: Asking about pain management with PCA involves assessing the effectiveness of the pain control method and potential side effects, which should be done by a licensed nurse.