Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

During the second post-operative day after a right below-the-knee amputation, the practical nurse is planning positioning strategies for the client. Which specific action should the nurse implement to prevent the development of a hip flexion contracture?

  1. Assist the client into a prone position for 30 minutes three to four times daily.Cevap
  2. B
    Elevate the right residual limb continuously on a soft pillow.
  3. C
    Maintain the head of the bed in a high-Fowler's position during waking hours.
  4. D
    Place a trochanter roll along the outer aspect of the right hip and thigh.

Cevap

Assist the client into a prone position for 30 minutes three to four times daily.
Placing the client in a prone position for 20 to 30 minutes several times a day fully extends the hip joints. This stretches the hip flexor muscles, which is the most effective basic care measure to prevent flexion contractures following a lower extremity amputation. Contractures can severely impede the future fitting and use of a prosthetic limb.

Adım Adım Çözüm

1
Analyze the clinical scenario to identify the client's primary risk.
The client is 48 hours post-operative from a lower extremity amputation and is at high risk for hip flexion contractures due to muscle shortening.
Identifying the specific post-operative complication allows the nurse to select the correct preventive basic care measure.
2
Evaluate the anatomical effect of each positioning option on the hip joint.
Lying prone fully extends the hip joint, while elevating the limb or sitting upright promotes hip flexion.
The intervention must actively stretch the hip flexors to counteract the natural tendency to pull the limb into a bent, flexed position.

Anahtar Kavram

Proper post-operative positioning to prevent hip flexion contractures following lower extremity amputation.
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru