Question

A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

Answer 1

Correct Answers:

Supine with the right leg flexed at a 45-degree angle.

Rationale :

✓ After a femoral-popliteal bypass, the client should be placed supine with the affected leg extended and flat to promote optimal perfusion and prevent pressure or kinking of the graft. ✓ Flexing or elevating the leg may compromise blood flow or place stress on the surgical site. ✓ Proper positioning helps maintain arterial circulation, which is critical for graft patency and wound healing postoperatively.

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Answer 2

Correct Answers:

Had a prior anaphylactic reaction to penicillin.

Rationale :

✓ Cefazolin is a first-generation cephalosporin, and there is a known cross-reactivity in individuals who have had a severe allergic reaction to penicillin, such as anaphylaxis. ✓ Administering cefazolin to such clients increases the risk of a life-threatening reaction. ✓ The nurse must notify the provider and withhold the medication until an alternative is ordered. ✓ Cross-sensitivity is especially relevant with severe penicillin allergies.

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Answer 3

Correct Answers:

Call the health care provider if you notice that your stools are dark.

Rationale :

✓ Clopidogrel is an antiplatelet agent that inhibits platelet aggregation, increasing the risk of bleeding. ✓ Dark, tarry stools may indicate gastrointestinal bleeding, a serious adverse effect. ✓ Clients should be taught to report any signs of bleeding, such as unusual bruising, gum bleeding, or blood in urine/stools. ✓ This medication is often used in PAD to reduce clot risk, but bleeding complications require prompt evaluation.

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Answer 4

Correct Answers:

Anticonvulsants such as gabapentin.

Rationale :

💎Phantom limb pain is believed to originate from abnormal nerve signaling in the spinal cord and brain. 💎Gabapentin, an anticonvulsant, is commonly prescribed because it modulates nerve impulses and reduces neuropathic pain. 💎Unlike NSAIDs or opioids, which may offer limited relief for this type of pain, gabapentin specifically targets nerve-related pain mechanisms and is considered first-line therapy for phantom limb sensations.

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Answer 5

Correct Answers:

Rotate sites when injecting insulin glargine.
There is no peak of action for this insulin, which reduces the risk of hypoglycemia.

Rationale :

✔️ Rotate sites when injecting insulin glargine Repeated injections at the same site can lead to lipodystrophy, affecting insulin absorption. Site rotation preserves tissue integrity and ensures consistent insulin action. ✔️ No peak reduces risk of hypoglycemia Insulin glargine is a long-acting, basal insulin with a steady 24-hour effect and no pronounced peak, making it safer in terms of hypoglycemia risk, especially overnight.

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Answer 6

Correct Answers:

Supine with the stump flat on the bed.

Rationale :

✔️ Immediately after a below-the-knee amputation (BKA), the client should be kept supine with the stump flat to prevent hip contractures and facilitate healing. ✔️ Elevation or flexion of the residual limb in the early postoperative period increases the risk of joint contracture, which can hinder prosthesis use and mobility. ✔️ Prone positioning is beneficial later to stretch the hip, but not continuously for the first 24 hours.

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Answer 7

Correct Answers:

Obtain a pair of heavy-duty gloves to wear for cold exposures.

Rationale :

✓ Raynaud's disease involves vasospasms of small arteries, often triggered by cold exposure, resulting in pain and discoloration of the fingers and toes. ✓ Wearing insulated gloves protects the extremities and helps prevent spasms. ✓ Avoiding cold exposure is crucial in symptom management. ✓ Other options, like raising the hands or staying indoors, are less practical or ineffective in acute management.

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Answer 8

Correct Answers:

Rotate injection sites correctly.

Rationale :

✓ Rotating insulin injection sites helps prevent lipodystrophy—fatty tissue changes that impair insulin absorption and glycemic control. ✓ Clients should be educated to use different sites in a systematic way, such as rotating within a quadrant weekly. ✓ Consistent absorption enhances the effectiveness of insulin therapy and prevents glucose variability.

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Answer 9

Correct Answers:

Obtain a serum trough level.

Rationale :

💎Aminoglycosides have a narrow therapeutic range and are nephrotoxic and ototoxic. 💎Trough levels are measured just before the next dose to ensure the drug does not accumulate to toxic levels. 💎This is especially important in clients with impaired renal function. 💎 Peak levels assess efficacy, but trough levels are critical for safety.

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Answer 10

Correct Answers:

Increase fluid intake to 3 to 4 liters per 24 hours.

Rationale :

💎Trimethoprim-sulfamethoxazole (TMP-SMX) can cause crystalluria and nephrotoxicity. 💎 To prevent these effects, clients should be instructed to maintain high fluid intake (3–4 liters/day) to dilute the urine and promote renal clearance of the drug. 💎 Hydration helps avoid complications such as kidney stones or acute kidney injury. 💎 Sunlight exposure and concurrent use with certain diuretics (e.g., HCTZ) increase adverse effect risks and should be avoided.

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RN Medsurg Nurs200~RMC

No.

1 : A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

2 : The nurse receives an order to administer cefazolin to a client diagnosed with a urinary tract infection. The nurse withholds the medication and notifies the health care provider because the client:

3 : The client diagnosed with peripheral arterial disease (PAD) has a new prescription for clopidogrel. What information should the nurse include when teaching the client about this medication?

4 : Which prescribed medication for the client recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain?

5 : The nurse is discharging a client who was just prescribed insulin glargine daily at 2000. Which of the following should be included in the teaching? (SELECT ALL THAT APPLY)

6 : The nurse is caring for a client who has just returned to the nursing unit following a below-the-knee amputation (BKA) of the right leg. How should this client be positioned?

7 : A client diagnosed with Raynaud's disease is experiencing severe pain and spasms in the fingers and toes of their hands. What advice should the nurse include in the discharge instructions for this client?

8 : To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?

9 : The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

10 : A client is receiving trimethoprim-sulfamethoxazole. What information should the nurse include in the teaching about this medication?

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