Ready for today’s NCLEX-RN® question? Test your knowledge by determining the priority nursing action for a patient who had a below-the-knee amputation 12 hours ago.
The nurse on the medical surgical unit is caring for a patient who underwent a below-the-knee amputation 12 hours ago following a motor vehicle accident. Which is the nurse’s priority action?
A. Apply a circumferential compression bandage to the amputation site
B. Gently massage the skin of the residual limb toward the suture line
C. Elevate the foot of the bed, supporting the extremity on pillows
D. Position the client in a prone position for 20 minutes per day
Scroll down for the correct answer!
The correct answers to today’s NCLEX-RN® Question are…
C. Elevate the foot of the bed, supporting the extremity on pillows
Rationale: For the first 24 hours following a below-the-knee amputation, the nurse should elevate the foot of the bed and support the affected extremity on pillows to decrease swelling.
Major Takeaway
The priority nursing goals for a client with a lower extremity amputation are to provide postoperative care, monitor for complications, and provide emotional support. The nurse should begin by implementing routine postoperative interventions and instituting measures to promote comfort and healing. For the first 24 hours postoperatively, the nurse should elevate the foot of the bed and support the affected extremity on pillows to further decrease swelling. Then, after 24 hours, the nurse can discontinue elevating the extremity and begin positioning the client in a prone position twice daily for 20 to 30 minutes to help prevent flexion contractures of the hip. Also, the nurse will gently massage the skin of the residual limb towards the suture line to promote circulation and to help prevent scar tissue from adhering to the underlying bone. The nurse should then apply a compression bandage using a figure eight limb-wrapping technique to promote comfort, reduce swelling, and help mold the residual limb for a prosthesis. Avoid wrapping the extremity too tightly or in a circular pattern, as these can impair circulation.
Incorrect answer explanations
A. Apply a circumferential compression bandage to the amputation site
Rationale: A circumferential or circular pattern should be avoided when wrapping a compression bandage around the amputation site because it will impede circulation to the limb. The nurse should instead apply a compression bandage using a figure eight limb-wrapping technique to promote comfort, reduce swelling, and help mold the residual limb for a prosthesis.
B. Gently massage the skin of the residual limb toward the suture line
Rationale: After 24 hours, rather than 12 hours, the nurse should gently massage the skin of the residual limb towards the suture line to promote circulation and to help prevent scar tissue from adhering to the underlying bone.
D. Position the client in a prone position for 20 minutes per day
Rationale: After 24 hours, rather than 12 hours, the nurse should begin positioning the client in a prone position twice daily for 20 to 30 minutes to help prevent flexion contractures of the hip.

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