Question

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the resdual (remaining) limb and expects to note which finding?
a. pink color to the skin flap.
b.Hot feeling on palpation of the skin flap.
c. Serous fluid leaking from the skin flap incision .
d. Absent pulse at the proximal pulse point site closest to the skin flap.

Answer 1

Ans-)The nurse assessed the remaining limb and expect to note pink color to skin flap.

EXPLANATION : the primary focus of the nurse is to look for the symptoms which decide that there is no hemorrhage. At the end of residual limb, the flap of skin should be pink in colour. The portion around the knee should not be hot but should be warm because hotness indicates the sign of infection. At the proximal pulse area, the presence of pulse is compulsory. And in case if the nurse was not able to assess the pulse, then she should use Doppler and further if no pulse is detected then nurse should immediately notify it to surgeon or the doctor.