A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?

Align the client's joints with the joints on the frame.

Pad the CPM device with a thick pillow.

Place the client in high-Fowler's position.

Set the degree of flexion and extension as tolerated by client.

Answer and Explanation

The Correct Answer is A

Choice A: This is correct because aligning the client's joints with the joints on the frame can ensure proper functioning and comfort of the CPM device. The nurse should adjust the length and width of the device to fit the client's leg and secure it with straps.

Choice B: This is incorrect because padding the CPM device with a thick pillow can interfere with its movement and cause pressure on the leg. The nurse should use only thin padding or no padding at all for the CPM device.

Choice C: This is incorrect because placing the client in high-Fowler's position can cause flexion contractures and impair circulation in the leg. The nurse should place the client in supine or semi-Fowler's position with the leg elevated on pillows.

Choice D: This is incorrect because setting the degree of flexion and extension as tolerated by client can cause excessive pain and damage to the joint. The nurse should set the degree of flexion and extension according to the provider's prescription and gradually increase it as ordered.

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Correct Answer is B

Explanation

Choice A: This is incorrect because client status unchanged throughout shift is too vague and does not provide specific details about the client's condition and progress. The nurse should document any changes or interventions that occurred during the shift, such as vital signs, pain level, activity, and drainage.

Choice B: This is correct because abdominal wound dry, without redness is a clear and objective description of the client's wound appearance and healing. The nurse should document any signs of infection or complications, such as redness, swelling, warmth, or purulent drainage.

Choice C: This is incorrect because client received an adequate amount of fluid is too general and does not indicate the exact amount and type of fluid that the client received. The nurse should document the intake and output of the client, including any IV fluids, oral fluids, urine, stool, and drainage.

Choice D: This is incorrect because incision healing well is too subjective and does not reflect the actual assessment of the incision site. The nurse should document the size, color, and condition of the incision, as well as any sutures or staples.

A. Discard soiled wound care supplies in a trash receptacle outside the client's room. B. Administer antibiotic therapy before culturing the client's wound. C. Instruct visitors to perform hand hygiene for 15 seconds after leaving the client's room. D. Place the client in a private room with a private bathroom.

Correct Answer is D

Explanation

Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.

Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.

Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.

Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.

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A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?

Nursing Test Bank

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