Examkin

Soru

Zorluk: ZorBasic Care and Comfort

A surgical nurse is developing a daily care regimen for a client who is 48 hours postoperative following a right above-the-knee amputation. To prevent musculoskeletal complications and ensure safe hygiene practices, which intervention is most appropriate to include in the plan?

  1. Assist the client into a prone position for 20 to 30 minutes three to four times daily.Cevap
  2. B
    Prop the residual limb continuously on stacked pillows while the client rests in a supine position.
  3. C
    Transfer the client to a bedside chair to sit upright for at least four consecutive hours.
  4. D
    Assign the unlicensed assistive personnel (UAP) to evaluate the incision site for redness during the daily bed bath.

Cevap

Assist the client into a prone position for 20 to 30 minutes three to four times daily.
Following an above-the-knee amputation, the client is at a high risk for developing hip flexion contractures, which can severely impair future mobility and the ability to use a prosthesis. Assisting the client into a prone position for 20 to 30 minutes several times a day promotes full extension of the hip joint and is the standard nursing intervention to prevent these contractures.

Adım Adım Çözüm

1
Analyze the client's surgical procedure and postoperative timeframe.
The client is 48 hours post-above-the-knee amputation (AKA).
Identifying the procedure and timing helps determine the physiological risks, specifically hip flexion contractures which peak as a risk after the initial 24 hours.
2
Evaluate each intervention against the risk of hip flexion contractures.
Elevation on pillows and prolonged sitting both promote hip flexion and are contraindicated.
The hip must be periodically extended to maintain joint mobility for future prosthesis use.
3
Assess the delegation task for scope of practice compliance.
Delegating an incision evaluation to a UAP during a bed bath is inappropriate.
Assessment is strictly an RN responsibility.
4
Identify the action that safely promotes comfort and prevents complications.
Placing the client in a prone position for short intervals is the standard of care.
The prone position naturally extends the hip joint, directly counteracting the flexion contracture risk without compromising safety.

Anahtar Kavram

Postoperative Positioning and Contracture Prevention in Amputation
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru