A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn the CPM machine off while the client is eating.
Store the CPM machine on the floor when not in use.
Check the settings of the CPM machine every 12 hours.
Increase the range of motion rapidly when the CPM machine is used intermittently.
The Correct Answer is A
Choice A reason: This response is appropriate because it encourages the client to seek professional medical advice, ensuring they receive personalized recommendations based on their health status and needs. It also emphasizes the importance of a physical examination to rule out any contraindications or underlying health issues before starting any contraceptive method.
Choice B reason: Storing the CPM machine on the floor when not in use is not recommended as it can pose a tripping hazard and may not comply with safety standards. The machine should be stored properly according to the manufacturer's instructions to ensure safety and maintain the equipment's integrity.
Choice C reason: While barrier methods are a good option for preventing both pregnancy and sexually transmitted infections (STIs), suggesting a specific method without a full assessment of the client's needs and preferences is not ideal. It is better to involve a healthcare provider in the decision-making process.
Choice D reason: Increasing the range of motion rapidly when the CPM machine is used intermittently is not advised. Adjustments to the range of motion should be made gradually and according to the client's tolerance and the surgeon's orders. Rapid increases can cause pain and may hinder the healing process.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.
Correct Answer is C
Explanation
Choice A reason: Cheyne-Stokes respirations, characterized by a pattern of irregular breathing with periods of apnea, can be a sign of brain stem compression due to increased intracranial pressure. However, it is not typically the first sign of deteriorating neurological status.
Choice B reason: Pupillary dilation, especially if it is unilateral, can indicate pressure on the cranial nerves due to increased intracranial pressure. It is a concerning sign but may not be the first to appear as neurological function deteriorates.
Choice C reason: An altered level of consciousness is often the first sign of deteriorating neurological status in a patient with increased intracranial pressure. Changes in consciousness can range from slight disorientation or confusion to complete unresponsiveness.
Choice D reason: Decorticate posturing, which involves abnormal flexion of the arms with extension of the legs, indicates significant brain injury and is a later sign of increased intracranial pressure, not typically the first sign.
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