Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A practical nurse is caring for a client who is 24 hours postoperative following a right total knee arthroplasty. The client reports leg swelling and asks the nurse to place a pillow directly under the right knee for comfort. Which action should the nurse take?

  1. Elevate the right leg by placing a pillow under the lower calf and ankle, ensuring the knee remains fully extended.Cevap
  2. B
    Place a soft pillow directly under the right knee to alleviate the reported joint tension and promote comfort.
  3. C
    Ask the client why they feel they need a pillow placed under their surgical knee.
  4. D
    Maintain the right leg flat on the mattress without elevation to prevent the risk of joint dislocation.

Cevap

Elevate the right leg by placing a pillow under the lower calf and ankle, ensuring the knee remains fully extended.
Following a total knee arthroplasty, the primary basic care goals are to reduce edema and prevent flexion contractures. Elevating the leg by placing pillows under the lower calf and ankle allows for venous return while keeping the new knee joint straight and fully extended.

Adım Adım Çözüm

1
Analyze the client's request for comfort measures.
The client requested a pillow directly under the right knee for swelling and comfort.
Understanding the client's specific request helps the nurse determine if the intervention is safe and aligns with postoperative protocols.
2
Evaluate the safety of the requested position.
Placing a pillow directly under the knee is contraindicated post-total knee arthroplasty.
Knee flexion during the postoperative period can lead to flexion contractures, which severely limit future mobility and joint function.
3
Determine the appropriate alternative basic care intervention.
The nurse must elevate the leg to address the swelling while keeping the knee completely straight.
Supporting the lower calf and ankle elevates the extremity to promote venous return, safely managing the edema while maintaining the required knee extension.

Anahtar Kavram

Proper postoperative positioning for total knee arthroplasty emphasizes maintaining knee extension to prevent flexion contractures while appropriately managing edema.
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru