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Zorluk: OrtaBasic Care and Comfort

A client is recovering on the surgical unit 48 hours after undergoing a right above-the-knee amputation. Which basic care and comfort interventions should the nurse incorporate into the client's daily routine? Select all that apply.

  1. Position the client prone for 20 to 30 minutes three to four times daily.Cevap
  2. Wash the residual limb with mild soap and warm water, ensuring it is completely dry.Cevap
  3. C
    Elevate the right residual limb on two pillows while the client is resting in bed.
  4. D
    Delegate the assessment of the residual limb's skin integrity to the unlicensed assistive personnel.
  5. E
    Apply soft wrist restraints immediately if the client becomes confused and attempts to touch the surgical dressing.
  6. Instruct the client to actively push the residual limb down against the mattress while supine.Cevap

Cevap

The correct interventions are positioning the client prone periodically, washing the residual limb with mild soap and water, and instructing the client to perform isometric exercises by pushing the limb against the mattress.
Prone positioning for 20 to 30 minutes several times a day stretches the flexor muscles and is a primary intervention to prevent hip flexion contractures, which are a major complication after lower extremity amputations. Washing the limb with mild soap and water maintains skin integrity without causing excessive dryness or maceration. Instructing the client to push the residual limb against the mattress consists of isometric exercises that strengthen muscles and prepare the limb for a prosthetic device.

Adım Adım Çözüm

1
Analyze the client's postoperative timeline and surgical procedure.
The client is 48 hours post-op from a right above-the-knee amputation.
The timeline is critical, as interventions that are acceptable in the first 24 hours (like elevation) become contraindicated later due to contracture risks.
2
Evaluate each intervention for safety, scope of practice, and physiological benefit.
Prone positioning, hygiene, and isometric exercises are beneficial and safe. Elevation, delegation of assessment, and immediate restraints are contraindicated or outside the scope of practice.
Basic care and comfort must align with standard postoperative safety guidelines and legal nursing boundaries.

Anahtar Kavram

Postoperative amputation care focuses on preventing joint contractures, maintaining skin integrity, and preparing the residual limb for a prosthesis.
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Basic Care and Comfort

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