A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn off the CPM machine during mealtime.
Maintain the client's affected hip in an externally rotated position.
Instruct the client how to adjust the CPM settings for comfort.
Store the CPM machine under the client's bed when not in use.
The Correct Answer is A
- A. Correct. The nurse should turn off the CPM machine during mealtime, as it can interfere with the client's ability to eat and drink comfortably. The nurse should also turn off the CPM machine when transferring or repositioning the client, or when performing wound care or other interventions on the affected leg.
- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position, as external rotation can cause malalignment of the prosthesis and impair healing. The nurse should use pillows or wedges to support the leg and prevent rotation or abduction of the hip joint.
- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings, as this can compromise the prescribed range of motion and speed of the device. The nurse should follow the provider's orders and check with them before making any changes to the CPM settings. The nurse should also monitor the client's pain level and administer analgesics as needed to facilitate compliance with the therapy.
- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this can pose a safety hazard and damage the equipment. The nurse should place the CPM machine on a stable surface near the bed and ensure that it is plugged into a grounded outlet and has adequate battery backup in case of power failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Administering terbutaline is used to stop or slow down preterm labor contractions. In the given scenario, the client is in the latent phase of labor and is experiencing severe back pain. Terbutaline is not indicated for back pain during labor.
Choice B rationale:
Placing the client in a warm bath can provide comfort and relaxation, but it may not specifically alleviate back pain during labor. Additionally, warm baths are more commonly used for pain relief in early labor or during the active phase, not specifically for back pain.
Choice C rationale:
Applying counterpressure during each contraction is an appropriate intervention for relieving back pain during labor. Back pain is a common discomfort experienced by many women during labor, and counterpressure, often applied by a support person or nurse, can help alleviate the discomfort. It is a non-pharmacological method that can be effective in managing pain during labor.
Choice D rationale:
Requesting the provider prescribe a pudendal nerve block is not the first-line intervention for back pain during labor. Pudendal nerve blocks are used for pain relief during the second stage of labor (during delivery) and are typically administered by the provider if needed. It is not the appropriate intervention for back pain in the latent phase of labor.
Correct Answer is A
Explanation
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The correct answer is Choice A.
Choice A rationale: Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. By forming a committee, the nurse manager can gather different perspectives and insights from the staff members who are directly affected by the staffing issues. This will help in identifying the specific problems and coming up with effective solutions. Furthermore, involving the staff in the decision-making process can increase their acceptance of the changes and reduce resistance.
Choice B rationale: Providing support to staff members who are resistant to staffing changes is an important step, but it should not be the first action. Before providing support, the nurse manager needs to understand the specific issues causing the resistance. This can be achieved by forming a committee of staff members to investigate the staffing issues.
Choice C rationale: Scheduling a staff meeting to present the different options to staff members is a crucial step in the process. However, this should be done after the nurse manager has a clear understanding of the staffing issues and has identified potential solutions. Presenting options without first understanding the problem may lead to ineffective solutions and increased resistance from staff members.
Choice D rationale: Giving the staff members advance written notice of staffing changes is a necessary step to ensure transparency and to give staff members time to adjust. However, this should be done after the nurse manager has identified the staffing issues, explored potential solutions, and decided on the changes to be implemented.
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