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Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

A.

Withhold medication for phantom limb pain as it isn't real pain.

B.

Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible.

C.

Continue using the limb prosthesis even if skin appears irritated.

D.

Have the client lay prone for 30 minutes, 3-4 times a day.

Answer and Explanation

The Correct Answer is D

A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.  
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.  
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.  
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.
 


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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

  • Fall precautions: The client is disoriented, which significantly increases their risk of falls. Addressing this is the immediate priority for client safety.
  • Antibiotic therapy: The client is febrile and has foul-smelling urine, indicating a likely urinary tract infection (UTI). While important, initiating antibiotic therapy is secondary to ensuring the client's immediate safety from falls.

Correct Answer is B

Explanation

A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.

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