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Difficulty: MediumBasic Care and Comfort

A practical nurse is planning care for an adult client who underwent a right above-the-knee amputation two days ago. Which actions should the nurse implement to promote optimal healing and basic comfort? Select all that apply.

  1. Assist the client to lie on their abdomen for 30 minutes, three to four times a day.Answer
  2. B
    Keep the residual limb continuously elevated on a soft pillow to reduce swelling.
  3. Cleanse the intact skin surrounding the surgical site daily with mild soap and warm water.Answer
  4. D
    Administer prescribed intravenous push (IVP) opioid analgesics prior to physical therapy.
  5. Encourage active range-of-motion exercises for the unaffected extremities.Answer

Answer

The correct actions include assisting the client into a prone position several times daily, cleansing the intact skin with mild soap, and encouraging active range-of-motion exercises for unaffected extremities.
Appropriate basic care for a client 48 hours after an above-the-knee amputation focuses on preventing contractures via prone positioning, maintaining hygiene using mild soap and water on intact skin, and promoting general mobility through active range-of-motion exercises on unaffected limbs.

Step-by-Step Solution

1
Identify the primary risks and care needs for a client 48 hours post-amputation.
The main risks are hip flexion contractures, immobility complications, and impaired skin integrity.
Understanding the postoperative timeline is critical; interventions change significantly after the first 24 hours.
2
Evaluate the positioning options against contracture risks.
Prone positioning is indicated to extend the hip; elevating on a pillow is contraindicated after 24 hours.
Prolonged elevation causes the hip flexor muscles to shorten, leading to permanent contractures.
3
Assess the nursing actions for scope of practice compliance.
IVP medication administration is excluded from the practical nurse scope of practice.
The practical nurse must recognize boundaries of their licensure regardless of the client's pain level.
4
Select interventions that safely promote hygiene and mobility.
Basic skin cleansing and active ROM for unaffected limbs are appropriate basic care measures.
These actions maintain physiological integrity and prepare the client for future rehabilitation without causing harm.

Key Concept

Post-Amputation Positioning and Basic Care
Estimated Time:1m 30s
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Topics

Basic Care and Comfort

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