While planning care for a client who underwent a left below-the-knee amputation 48 hours ago, the practical nurse considers interventions to promote mobility and prevent musculoskeletal complications. Which actions should be included in the client's care plan? Select all that apply.
- Assist the client into a prone position for 30 minutes three times a day.Answer
- BElevate the left residual limb on two stacked pillows while the client is supine.
- Ensure the client's left knee remains fully extended while resting in bed.Answer
- DRaise the bed's knee gatch to prevent the client from sliding downward.
- EEncourage the client to sit upright in a bedside chair for 4 to 6 hours continuously.
- Instruct the client to perform active range-of-motion exercises with the right leg.Answer
Answer
The nurse should assist the client into a prone position periodically, ensure the left knee remains extended, and instruct the client to perform active range-of-motion exercises on the unoperated leg.
The correct interventions focus on preventing flexion contractures and maintaining strength. Prone positioning stretches the hip flexors, keeping the knee extended prevents hamstring shortening, and exercising the unaffected limb preserves mobility for future rehabilitation.
Step-by-Step Solution
Key Concept
Prevention of hip and knee flexion contractures is a primary basic care priority following a below-the-knee amputation.