All of the following are the nursing interventions in case of below knee amputation EXCEPT :

IGNOU PB. Bsc. Nsg. Entrance-2025

Medical & Surgical Nursing

Medium

Appeared in: IGNOU PB. Bsc. Nsg. Entrance-2025

Explanation

The question asks for the exception, meaning the incorrect nursing action.
Keeping the stump in a flexed position is contraindicated because it leads to the development of flexion contractures at the knee.
Flexion contractures shorten the muscles and tendons, making it difficult or impossible to straighten the leg.
A straight, extended stump is necessary for proper fitting and use of a prosthetic limb.
Therefore, promoting flexion is the one action a nurse should NOT take.

Option B: This is a correct and critical nursing intervention. Amputation involves severing major blood vessels, creating a high risk for postoperative hemorrhage. The nurse must monitor vital signs and inspect the stump dressing for bleeding.
Option C: This is a correct and essential nursing intervention. Close inspection is required to assess wound healing, check for signs of infection, monitor for skin breakdown, and ensure adequate tissue perfusion.
Option D: This is a correct and important nursing intervention. Quadriceps setting exercises help maintain muscle strength and tone in the thigh, which is crucial for stabilizing the knee and controlling a future prosthesis.

Clinical Relevance

Nursing practice connection: Knowing Post-operative nursing care for a patient with a below-knee amputation helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Preventing contractures is a cornerstone of amputation care. A flexion contracture can severely delay or completely prevent a patient's return to mobility and independence.
Patient education is critical. The nurse must explain to the patient and family why keeping the leg straight is so important, as the flexed position may feel more comfortable initially.
What if? If the patient reports severe phantom limb pain, the nurse should administer prescribed analgesics and use non-pharmacological methods (like mirror therapy), but still maintain correct stump positioning. Pain management should not come at the cost of creating a contracture.

How to Approach the Question

First, identify the keywords in the question: 'below knee amputation', 'nursing interventions', and especially 'EXCEPT'.
The word 'EXCEPT' signals that you are looking for the one option that is an incorrect or contraindicated action.
Evaluate each option based on standard principles of post-amputation care.
Ask yourself for each option: 'Is this a recommended action for a BKA patient?'
Option A: Is keeping the stump flexed recommended? No, it causes contractures.
Option B: Is monitoring for bleeding recommended? Yes, it's a priority.

Concept Tested & Keywords

Concept Tested: Post-operative nursing care for a patient with a below-knee amputation.
Stem keywords: below knee amputation, nursing interventions
Lead-in keywords: EXCEPT
Negative lead-in flag: The question asks for the intervention that should NOT be performed.

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