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Difficulty: MediumBasic Care and Comfort

A client who underwent a right above-the-knee amputation 36 hours ago is receiving care on the surgical unit. Which actions should the practical nurse include in the client's care plan to promote comfort, maintain skin integrity, and prevent complications? Select all that apply.

  1. Position the client in a prone position for 20 to 30 minutes three to four times a day.Answer
  2. B
    Elevate the right residual limb on pillows continuously while the client is resting in bed.
  3. Wash the residual limb with mild soap and warm water, gently patting it completely dry.Answer
  4. D
    Encourage the client to sit in a bedside chair for at least 4 hours at a time to increase endurance.
  5. Encourage the client to perform active range-of-motion exercises with the unaffected extremities.Answer
  6. F
    Serve the facility's standard postoperative meal without verifying the client's cultural dietary preferences.

Answer

The correct actions are positioning the client prone for 20 to 30 minutes several times daily, washing the residual limb gently with mild soap and water, and encouraging active range-of-motion exercises for the unaffected extremities.
After the first 24 hours following an amputation, prone positioning for short intervals is crucial to prevent hip flexion contractures. Proper hygiene, such as washing with mild soap and patting the skin dry, maintains skin integrity. Active range-of-motion exercises for the unaffected limbs prevent muscle deconditioning and promote overall physical mobility.

Step-by-Step Solution

1
Identify the client's surgical procedure (above-the-knee amputation) and the timeframe (36 hours postoperative).
The client is past the initial 24-hour acute swelling phase and is at high risk for hip flexion contractures.
Care priorities shift from purely managing acute postoperative swelling to preventing long-term mobility complications.
2
Evaluate positioning interventions to prevent contractures.
Prone positioning is identified as beneficial, while elevating the limb on pillows or prolonged sitting is contraindicated.
After 24 hours, keeping the hip flexed (via pillows or sitting) causes the muscles to shorten, whereas prone positioning stretches them out.
3
Evaluate basic hygiene and skin care interventions.
Washing the residual limb with mild soap and patting it dry is selected as a correct action.
Proper hygiene maintains skin integrity without causing mechanical irritation to the surgical site.
4
Evaluate mobility interventions for the rest of the body.
Active range-of-motion exercises for unaffected limbs are selected as a correct action.
Strengthening the unaffected limbs prevents deconditioning and is critical for the client's future ability to perform transfers and use assistive devices.
5
Evaluate nutritional and holistic comfort interventions.
Ignoring cultural dietary preferences is identified as incorrect.
Providing adequate and culturally appropriate nutrition is a fundamental aspect of basic care.

Key Concept

Basic care, comfort, and proper positioning to prevent complications following an above-the-knee amputation.
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Topics

Basic Care and Comfort

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