Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A client is 48 hours postoperative following a right above-the-knee amputation and is preparing to begin physical therapy. To prevent common postoperative complications associated with this procedure, which of the following actions should the nurse take?

  1. A
    Elevate the residual limb continuously on a pillow to reduce postoperative tissue swelling.
  2. Position the client prone for 20 to 30 minutes several times a day.Cevap
  3. C
    Delegate the initial skin assessment of the residual limb to unlicensed assistive personnel.
  4. D
    Apply soft wrist restraints at night to prevent the client from touching the incision.

Cevap

The nurse should position the client prone for 20 to 30 minutes several times a day to prevent hip flexion contractures.
Positioning the client prone for 20 to 30 minutes, 3 to 4 times daily, is an essential basic care measure after a lower extremity amputation. This position actively extends the hip joint, preventing the development of hip flexion contractures, which can severely impair the client's future ability to be fitted for and independently walk with a prosthesis.

Adım Adım Çözüm

1
Identify the primary postoperative complication risk.
The primary physical mobility risk for a client with an above-the-knee amputation is the development of a hip flexion contracture.
Prolonged flexion of the hip joint impairs the ability to properly fit and walk with a prosthetic limb in the future.
2
Evaluate the timing of the nursing interventions.
The client is 48 hours postoperative.
While limb elevation is appropriate during the first 24 hours to reduce acute edema, it is contraindicated after this period because it keeps the hip locked in a flexed state.
3
Select the intervention that counteracts the risk factor safely.
Assisting the client into a prone position is the correct evidence-based action.
Prone positioning physically extends the hip joint, counteracting the tendency for contracture formation.

Anahtar Kavram

Prevention of flexion contractures following lower extremity amputation.
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru