Final answer:
The nurse should explain the risks of flexion contracture to the client because maintaining the residual limb in a proper position post-amputation is crucial to prevent contractures and ensure effective rehabilitation.
Step-by-step explanation:
When caring for a client who has had a below-the-knee amputation, the nurse encountering a patient resting with their residual limb supported on a pillow should address the potential development of a flexion contracture. After an amputation, the patient must maintain good positioning to avoid contractures, which can occur when muscles and tendons shorten due to being in a bent position for an extended period.
The most appropriate action for the nurse in this situation would be (b) to explain the risks of flexion contracture to the client. This educates the patient on the importance of proper limb positioning to promote healing and prepare for a prosthesis. The nurse needs to inform the patient why it’s important not to keep the limb elevated on a pillow for long periods, as this could lead to the knee remaining in a bent position, making straightening difficult.
Explaining this detail to the patient aids in their understanding and helps prevent complications, contributing to a better rehabilitation outcome. This approach should be pursued before considering other actions, such as transferring the client to a sitting position or encouraging active range of motion (ROM) exercises, which could be part of the long-term rehabilitation plan discussed with the surgeon and physical therapist.
While informing the surgeon and performing ROM exercises are important in the comprehensive care of an amputee, addressing positioning concerns for immediate and preventative care takes precedence in this scenario.