A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?

Correct Answer: A

Rationale: The correct answer is A: Encouraging the patient to turn from side to side and to assume a prone position. This measure is essential for preventing hip flexion contractures after a below-the-knee amputation. Turning from side to side and assuming a prone position help in maintaining proper positioning and preventing hip flexion contractures by stretching the hip extensors and preventing the hip from being in a prolonged flexed position. Choice B is incorrect because initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation may be too late to prevent contractures. Choice C is incorrect as minimizing movement of the flexor muscles of the hip can actually lead to contractures. Choice D is also incorrect as sitting in a chair for extended periods can promote hip flexion contractures.

Correct Answer: B

Rationale: The correct answer is B: Flush the wound bed with sterile saline. Prior to obtaining a wound culture specimen, flushing the wound bed with sterile saline helps remove debris and contaminants. This step ensures that the specimen collected is not contaminated, providing accurate culture results. Applying clean gloves (A) is important but does not directly impact the quality of the specimen. Cleansing the wound with antimicrobial solution (C) may interfere with the culture results by killing bacteria present. Keeping the wound open to air for several minutes (D) does not contribute to obtaining a clean specimen.

Correct Answer: B

Rationale: The correct answer is B: Serum protein level 7.1 g/dL. This indicates effective teaching as it shows an improvement in the patient's nutritional status. Serum protein levels reflect protein intake and liver function, which are crucial for healing after burns. Weight loss (A) is not indicative of nutritional improvement in this context. Low serum albumin level (C) suggests protein malnutrition, not improvement. Choice D is not a valid option.

Correct Answer: D

Rationale: The correct answer is D: Suspected tissue injury. This classification is appropriate because the skin presentation described does not meet the specific criteria for Stage III or IV ulcers, which involve skin breakdown and tissue damage extending into deeper layers. The term "unstageable" is used when the wound bed is obscured, usually by eschar or slough, making it impossible to determine the depth of tissue damage. In this case, the presence of a blood-filled blister and pain suggests a superficial injury without visible tissue loss, indicating a suspected tissue injury rather than a defined stage of ulcer development. This classification allows for further assessment and monitoring to determine the extent of tissue damage.

Correct Answer: A

Rationale: The correct answer is A: keratin. Keratin is a fibrous structural protein that is the main component of hair, epidermis, and nails. It provides strength, durability, and protection to these structures. Vitamin D (choice B) is important for bone health and is not a component of hair, epidermis, or nails. Adipose tissue (choice C) is fat tissue and is not a component of these structures. Collagen (choice D) is a different type of protein found in connective tissues such as tendons and ligaments, not in hair, epidermis, or nails.