The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?

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Fundamentals Wound Care and Skin Integrity Questions Questions

Question 1 of 5

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?

Correct Answer: C

Rationale: Rewrapping with an elastic compression bandage maintains pressure to reduce edema and shape the residual limb for prosthetic fitting, addressing the immediate need after the bandage comes off.

Question 2 of 5

Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?

Correct Answer: B

Rationale: Placing a tuning fork on the big toe tests vibration sense (via cranial nerve VIII and peripheral nerves), a standard neurological assessment technique.

Question 3 of 5

The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.

Correct Answer: A

Rationale: Yellow spots may indicate retinopathy, requiring immediate medical evaluation.

Question 4 of 5

The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention should the nurse implement?

Correct Answer: B

Rationale: SIADH causes water retention; daily weights and nausea/vomiting assessment monitor fluid overload.

Question 5 of 5

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?

Correct Answer: D

Rationale: Symptomatic bradycardia (dizziness, hypotension) requires pacing to increase heart rate.

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