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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.

A. Remove indwelling urinary catheter when no longer indicated B. Elevate affected limb at chest level C. Assist the adolescent with ambulation from bed to chair D. Perform neurovascular assessments every hour E. Apply warm packs to right extremity for the first 24hrs

Correct Answer is ["A","B","D"]

Explanation

The correct answers are A, B, and D.

Choice A reason:

Removing an indwelling urinary catheter when it is no longer indicated is a standard postoperative care practice. It helps to reduce the risk of urinary tract infections (UTIs), which are common complications associated with prolonged catheter use. The normal practice is to remove the catheter as soon as the patient can use the bathroom independently or when medically advised.

Choice B reason:

Elevating the affected limb at chest level can help reduce swelling and improve venous return. This is particularly important after surgery involving the lower extremities to prevent edema and promote circulation. Proper elevation assists in managing pain and preventing complications such as deep vein thrombosis (DVT).

Choice C reason:

Assisting with ambulation from bed to chair immediately after surgery may not be appropriate, especially if the adolescent has had surgery on the lower extremity. It is essential to wait for the physician's evaluation and specific instructions regarding weight-bearing and movement post-surgery.

Choice D reason:

Performing neurovascular assessments every hour is crucial after surgery on an extremity. This involves checking for sensation, motor function, color, temperature, capillary refill, and pulse strength. The normal capillary refill time is less than 2 seconds; a refill time of 4 seconds, as noted in the assessment, is abnormal and warrants close monitoring. Frequent assessments help in early detection of complications such as compartment syndrome.

Choice E reason:

Applying warm packs to the right extremity for the first 24 hours post-surgery is not recommended. Warm packs can increase circulation to the area, potentially increasing swelling and bleeding. Instead, cold packs are usually applied to reduce swelling and provide pain relief. The use of warm packs can be considered after the initial 24-hour period, depending on the surgeon's instructions and the wound's response.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Correct Answer is B

Explanation

Correct Answer is ["A","B","D"]

Explanation

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