The nurse is caring for a client who has returned to the nursing unit from the post anesthesia care unit (PACU) 40 minutes ago following an above the knee amputation (AKA) of the right leg. In which position should the nurse place the client at this time?
Prone with arms elevated
Supine with the stump flat on the bed
Supine with the stump supported on pillows
Reverse Trendelenburg
The Correct Answer is C
A. While positioning a patient prone can help with certain surgical recovery situations, it is not typically used immediately after an above-the-knee amputation. Additionally, elevating the arms may not provide any benefit and could cause discomfort.
B. This position can increase the risk of contractures in the residual limb, especially with an above-the- knee amputation. Keeping the stump flat may also lead to swelling and discomfort.
C. This position allows for proper elevation of the stump, which can help reduce swelling and promote healing. Supporting the stump on pillows prevents the risk of contractures and maintains the limb in a neutral position. It provides comfort and stability while facilitating blood flow.
D. While this position can help with venous return and reduce the risk of complications such as orthostatic hypotension, it is not specifically beneficial for an above-the-knee amputation recovery. It may not adequately address the need for proper stump support and elevation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B. While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C. Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D. Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.
Correct Answer is D
Explanation
A. While an elastic bandage can provide some compression to control bleeding, its primary purpose post-amputation is not to prevent bleeding but to support the healing process. It does help cover the incision, but this is not its main function in the context of shaping the stump.
B. Phantom limb pain is a common phenomenon after amputation, where the patient feels sensations in the amputated limb. Wrapping the stump may provide some psychological comfort, but the elastic bandage does not directly decrease phantom limb pain.
C. While adequate compression can help with circulation, the primary function of wrapping the stump is not to prevent blood clots. Preventing blood clots is more relevant to immobilization and other measures, particularly in the early postoperative period.
D. The elastic bandage helps to compress the soft tissue of the stump, promoting a well-shaped residual limb. This shaping is important for fitting prosthetics later and helps minimize edema (swelling) in the area post-surgery.
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