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 B
Explanation
The priority nursing intervention in the immediate post-operative period for a patient who has undergone amputation is to assess the surgical incision for signs of infection. Infection is a common concern after surgery, and early detection and intervention are crucial to prevent complications and promote healing.
a. Administering pain medications as prescribed: Pain management is important for the patient's comfort and well-being, but it is not the priority nursing intervention immediately after amputation. Assessing the surgical incision for signs of infection takes precedence to prevent potential complications.
c. Applying a compression bandage to the residual limb: While compression bandages may be used as part of the post-operative care, they are not the priority intervention immediately after amputation. Ensuring the surgical site's integrity and preventing infection are more critical in the early post-operative period.
d. Providing emotional support and counseling: Emotional support and counseling are essential for the patient's overall well-being, but they are not the priority nursing intervention in the immediate post-operative period. The focus at this time is on physical assessment and early detection of any complications.
Correct Answer is B
Explanation
Acute compartment syndrome is a medical emergency where increased pressure within a muscle compartment compromises blood flow and can lead to tissue damage and permanent disability. In severe cases, where the condition is not relieved promptly, emergency amputation may be necessary to prevent further tissue damage and save the patient's life.
a. Acute appendicitis: Acute appendicitis is a condition involving inflammation of the appendix and typically requires surgical removal of the appendix (appendectomy) but not amputation.
c. Urinary tract infection: A urinary tract infection is a common infection that is not an indication for amputation. It is usually treated with antibiotics.
d. Minor laceration: A minor laceration does not require amputation. It can typically be treated with wound care and, if needed, sutures or adhesive strips.
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