The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action?
A) Inform the surgeon of this finding.
B) Explain the risks of flexion contracture to the patient.
C) Transfer the patient to a sitting position.
D) Encourage the patient to perform active ROM exercises with the residual limb.
Ans: B
Feedback:
The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the patient's surgeon. Encouraging exercise or transferring the patient does not address the risk of flexion contracture.
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