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 B
Explanation
This is the correct time to start monitoring for hypoglycemia. The insulin would have started working by this time, and the nurse can assess for any signs of low blood sugar, such as sweating, shakiness, or confusion.
Correct Answer is B
Explanation
A. Loss of hair on the lower extremities can be a common sign of chronic PAD, indicating reduced blood
flow. While it’s an important observation, it is not an immediate concern.
B. Cold legs can indicate poor blood flow, which is a significant concern in PAD. The use of a heating pad can pose a risk of burns due to impaired sensation, especially in clients with poor circulation. This statement warrants immediate intervention, as the nurse should educate the client against using heat sources that can cause injury and assess the client's circulation and potential complications.
C. This describes claudication, a common symptom of PAD, where pain occurs in the legs due to inadequate blood flow during physical activity. While it indicates worsening symptoms of PAD, it is not an immediate emergency.
D. Reddish discoloration (rubor) when the legs are dependent can indicate blood pooling due to decreased venous return or arterial insufficiency. While this observation is significant and requires monitoring, it is not as urgent as the concern related to using a heating pad.
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