Examkin

Question

Difficulty: MediumBasic Care and Comfort

A nurse is providing care for a client who had a right below-the-knee amputation 36 hours ago. The client reports mild discomfort and stiffness in the affected leg. Which nursing action is the most appropriate?

  1. Assist the client into a prone position for 20 to 30 minutes, three to four times a day.Answer
  2. B
    Elevate the residual limb on a pillow to decrease swelling and promote comfort.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to assess the skin integrity of the residual limb.
  4. D
    Encourage the client to sit in a bedside chair with the knees flexed for the majority of the day.

Answer

The most appropriate action is to assist the client into a prone position for 20 to 30 minutes, three to four times a day.
Assisting the client into a prone position for 20 to 30 minutes several times a day is the correct intervention. This position actively stretches the flexor muscles of the hip and knee, which is a critical measure to prevent flexion contractures following a lower extremity amputation. Contractures can severely limit mobility and complicate or prevent the future use of a prosthesis.

Step-by-Step Solution

1
Identify the time elapsed since the amputation.
The client is 36 hours post-operative.
Positioning protocols change significantly after the first 24 hours to transition from edema management to contracture prevention.
2
Recognize the primary positioning risk for this client.
Hip and knee flexion contractures are a major risk following a below-the-knee amputation.
Flexion contractures can prevent the successful fitting and use of a prosthetic limb.
3
Determine the correct positioning intervention.
The prone position is indicated.
Lying prone stretches the flexor muscles of the hip and knee, directly counteracting the tendency for contractures to form.

Key Concept

Prevention of flexion contractures post-amputation
Rate this question

Topics

Basic Care and Comfort

More questions from this topic