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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Troy, 27 years old, suffered from multiple injuries after his car crashed into a moving vehicle. He was then rushed to a nearby hospital where his left leg was amputated below the knee. After surgery, the physician’s orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under Troy’s amputated limb. The nursing action is to:
  1. Leave the pillow, as his stump is elevated
  2. Remove the pillow and elevate the foot of the bed
  3. Leave the pillow and elevate the foot of the bed
  4. Check with the physician and clarify the orders
Explanation
Answer - B - The orders call for bed elevation (this is done to reduce edema and prevent hemorrhage). A pillow under the stump may lead to a flexion contracture of the hip joint, so this is contraindicated. Also, further teaching is indicated so that the nursing assistant understands why the pillow is contraindicated.
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