1. A nurse is caring for a patient who has undergone replantation of a body part: What might
the saliva of leeches be used to treat in this patient?
a. Inadequate arterial blood flow
b. Venous insufficiency
c. Venous congestion
d. Increased arterial blood flow
ANS: C
Leeches are used to treat venous congestion:
DIF: Cognitive Level: Comprehension REF: p: 907 OBJ: 4 | 5
TOP: Replantation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. A patient who amputated his thumb in a lawnmower accident hands the emergency
department nurse his thumb in a glass jar: What is the best action for the nurse to
implement?
a. Place the thumb in a baggie with iced lactated Ringer solution:
b. Wrap the thumb in plastic wrap and place it on ice:
c. Leave the thumb in the jar and place it in the refrigerator:
d. Wrap the thumb in a cloth saturated with normal saline and place it in a baggie:
ANS: D
The amputated part should be wrapped in a towel soaked with normal saline solution,
placed in a baggie, and put in a cool bath:
DIF: Cognitive Level: Application REF: p: 906 OBJ: 4
TOP: Care of the Amputated Thumb KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. A patient who has a below-the-elbow prosthesis shows the home health care nurse the
residual limb, which is red, edematous, and warm to touch: What should the nurse
instruct this patient to do?
a. Apply soothing lotion to the residual limb before replacing the prosthesis:
b. Dampen the prosthetic limb sock to hydrate and cool the residual limb:
c. Pad the socket with lamb’s wool and replace the prosthesis:
d. Leave the prosthesis off and notify physician:
, ANS: D
An inflamed residual limb suggests an infection: the prosthesis should be removed,
the limb should be gently cleansed with soap and water, and the physician should be
notified:
DIF: Cognitive Level: Application REF: p: 903 OBJ: 5
TOP: Infection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
4. A child comes to the school nurse with his index finger partially amputated and hanging
by a shred of skin and muscle: What is the best action by the nurse?
a. Flush the hand with warm water and wrap it in a towel:
b. Carefully cut the skin holding the finger and wrap the finger and hand in a clean
towel:
c. Pinch the finger to stop the bleeding and take the child to the hospital:
d. Wrap the hand and finger securely and place it on an ice water–filled plastic bag:
ANS: D
The nurse should leave the shred of skin and muscle intact, wrap the hand and finger
in a towel soaked in normal saline, and place it on a cool surface:
DIF: Cognitive Level: Application REF: p: 906 OBJ: 4
TOP: Partial Amputation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. What nursing action should be implemented in the postoperative care for a patient with
replantation of the right thumb?
a. Decreasing the temperature of the room to 70 F
b. Elevating the hand but keeping it below the level of the heart
c. Offering coffee, tea, or cola to help increase fluid intake
d. Placing an antiembolus sleeve on the right arm
ANS: B
Slight elevation of the hand will encourage drainage but not affect arterial perfusion:
the room temperature should be 80 F: the patient should avoid all caffeine drinks and
tight clothing or dressings:
DIF: Cognitive Level: Application REF: p: 907 OBJ: 4
TOP: Nursing Care of Replantation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. A nurse is caring for a patient with a recent below-the-knee amputation: What should the
nurse recommend to this patient to prevent the loss of calcium and protein?
a. Drink 1 to 2 L of fluid daily:
b. Ingest at least four milk products each day:
c. Ambulate 30 minutes a day:
, d. Take vitamin supplements daily:
ANS: C
Even a small amount of ambulation will decrease the loss of calcium and protein:
DIF: Cognitive Level: Application REF: p: 906 OBJ: 4
TOP: Postoperative Ambulation KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
7. What are late signs of hemorrhage in the postoperative period after an amputation?
a. Restlessness and increased respirations
b. Cyanosis and hypotension
c. Confusion and seizures
d. Headache and hypertension
ANS: B
Cyanosis and hypotension are late signs of hemorrhage in the postoperative period
after an amputation:
DIF: Cognitive Level: Comprehension REF: p: 902 OBJ: 4
TOP: Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. A nurse is aware that a patient who is having his leg amputated is also having a prosthesis
fitted during at the same time as the surgery: Which fact should the preoperative teaching
plan include?
a. Extra preoperative medications will be needed:
b. A rigid dressing will be applied to accommodate the prosthesis:
c. A series of temporary prostheses will be put in place before the permanent one:
d. Wiring the residual limb will be needed to ensure acceptance of the prosthesis:
ANS: B
A rigid dressing will be applied to the residual limb to accommodate the prosthesis
immediately after surgery:
DIF: Cognitive Level: Application REF: p: 900 OBJ: 3
TOP: Preoperative Teaching KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9. A patient asks when he should expect to be up and walking after his below-the-knee
amputation: When should the nurse assure him that most people with amputations can
fully bear weight?
a. 3 weeks
b. 1 month
c. 6 weeks
, d. 3 months
ANS: D
Most people with amputations can fully bear weight 3 months after surgery:
DIF: Cognitive Level: Comprehension REF: p: 900 OBJ: 5
TOP: Amputation Recovery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The verbalization of microvascular precautions is a criterion for measuring the
achievement of which outcome?
a. Adequate circulation in the replanted limb
b. Pain relief
c. Patient knowledge of therapeutic measures
d. Adjustment to change in appearance and function
ANS: C
Verbalizing the information related to microvascular precautions is evidence of the
patient’s achievement of having acquired the necessary knowledge:
DIF: Cognitive Level: Knowledge REF: p: 907 OBJ: 5
TOP: Nursing Care Planning KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
11. Which postoperative observation must be reported to the physician immediately?
a. Brownish-red drainage on the dressing, which is damp
b. Respirations of 20 breaths/min
c. Pulse of 72 beats/min
d. Bright-red bleeding
ANS: D
Bright-red bleeding is not expected and indicates hemorrhage: Direct pressure should
be applied over the dressing and the physician or charge nurse should be notified:
DIF: Cognitive Level: Comprehension REF: p: 902 OBJ: 4
TOP: Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. A home health care nurse suspects a neuroma in a patient who had an above-the-knee
amputation 1 month earlier: Which complaint by the patient led the nurse to suspect a
neuroma?
a. Area of swelling and bruising on distal portion of residual limb
b. Prickling sensation over residual limb
c. Sharp severe pain in the residual limb
d. Area of numbness on distal portion of residual limb
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ExamsRevision. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $6.93. You're not tied to anything after your purchase.
