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Difficulty: HardBasic Care and Comfort

During the morning shift, a nurse provides care for a client who underwent a right above-the-knee amputation 48 hours ago. The client is medically stable and preparing to begin physical therapy. To promote optimal physical mobility and prevent common musculoskeletal complications, which intervention should the nurse implement?

  1. Assist the client into a prone position for 20 to 30 minutes three to four times a day.Answer
  2. B
    Elevate the right residual limb continuously on a pillow while the client rests in a supine position.
  3. C
    Encourage the client to sit upright in a bedside chair for four consecutive hours to build endurance.
  4. D
    Instruct unlicensed assistive personnel to evaluate the incision site for redness during morning hygiene.

Answer

Assist the client into a prone position for 20 to 30 minutes three to four times a day.
Following an above-the-knee amputation, the most significant risk to physical mobility is the development of a hip flexion contracture, which can prevent the client from successfully wearing and walking with a prosthesis. Placing the client in a prone position for 20 to 30 minutes several times a day physically stretches the hip flexor muscles, maintaining joint extension and preventing contracture formation.

Step-by-Step Solution

1
Identify the primary complication risk for a client 48 hours post-above-the-knee amputation.
The client is at high risk for hip flexion contractures, which impede future prosthetic use.
Surgical trauma and flexor muscle dominance tend to pull the residual limb into a flexed position.
2
Evaluate the clinical interventions based on their effect on hip joint flexion.
Prone positioning extends the hip joint, while prolonged sitting or pillow elevation flexes the hip joint.
Extension prevents contracture formation, whereas prolonged flexion causes muscle shortening.
3
Select the nursing action that safely prevents contractures while adhering to the standard scope of practice.
Assisting the client into a prone position is the correct, safe, and effective intervention.
It directly counteracts the contracture risk without inappropriately delegating nursing assessments.

Key Concept

Prevention of hip flexion contractures following an above-the-knee amputation requires specific positioning strategies, including periodic prone positioning and avoiding residual limb elevation after the first 24 postoperative hours.
Estimated Time:1m 30s
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Topics

Basic Care and Comfort

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