NCLEX-RN

Category - Reduction of Risk

A nurse develops a plan of care for a client who will have a below-the-knee amputation. The nurse should not include which of the following postoperative actions to prevent complications?
  1. During the first 24 hours, the foot of the bed is elevated.
  2. During the first 24 hours, a pillow is placed under the stump.
  3. During the first 24 hours, the stump is not elevated.
  4. After 24 to 48 hours, position the client prone with a pillow under the abdomen and stump.
Explanation
Answer - B - During the first 24 hours, the foot of the bed is elevated to reduce edema, but the stump is not elevated with a pillow. Elevation with a pillow within the first 24 hours can cause contracture of the hip joint. After 48 hours, the client is positioned prone with a pillow under the abdomen and the stump.
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