The nurse is caring for a patient who underwent an above-the-knee amputation. What is the priority nursing intervention to prevent hip flexion contractures?
Performing passive range of motion exercises to the hip joint
Elevating the residual limb on a pillow
Administering analgesics as prescribed
Providing emotional support and counseling
The Correct Answer is A
The priority nursing intervention to prevent hip flexion contractures after an above-the-knee amputation is performing passive range of motion exercises to the hip joint. Contractures are abnormal shortening and tightening of muscles and tendons, leading to restricted joint movement. Passive range of motion exercises help maintain joint flexibility and prevent contractures.
b. Elevating the residual limb on a pillow: Elevating the residual limb on a pillow is more applicable for preventing swelling and edema, not specifically for preventing hip flexion contractures.
c. Administering analgesics as prescribed: While pain management is essential for the patient's comfort, it is not directly related to preventing hip flexion contractures.
d. Providing emotional support and counseling: Emotional support and counseling are important aspects of care but are not directly related to preventing hip flexion contractures.
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Correct Answer is D
Explanation
The priority nursing intervention in the immediate post-operative period after an upper extremity amputation is to assess the surgical incision for infection. Early detection of signs of infection, such as redness, swelling, warmth, or drainage, is crucial to prevent complications and promote healing.
a. Managing phantom limb pain: While managing phantom limb pain is important, it may not be the priority nursing intervention immediately after the surgery. Assessing the surgical incision for infection and monitoring for any complications take precedence.
b. Ensuring proper prosthetic fitting: Prosthetic fitting is essential for functional outcomes, but it may not be the priority in the immediate post-operative period. It is addressed during the rehabilitation phase.
c. Elevating the residual limb on a pillow: Elevating the residual limb on a pillow is typically recommended for lower extremity amputations to reduce edema and promote venous return, not for upper extremity amputations.
Correct Answer is A
Explanation
The primary goal of positioning the residual limb in the post-operative period after amputation is to promote venous return and reduce swelling. Elevating the limb helps improve blood flow and reduce edema, which can enhance healing and prevent complications.
b. To improve the patient's comfort and relaxation: While positioning may improve the patient's comfort, the primary goal is related to physiological considerations such as venous return and swelling reduction.
c. To encourage early ambulation and mobility: Early ambulation and mobility are important components of post-operative care, but the primary goal of positioning is not directly related to encouraging ambulation.
d. To protect the surgical incision from contamination: Positioning the residual limb is not primarily intended to protect the surgical incision from contamination. Dressings and wound care techniques are used for this purpose.
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