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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: This is incorrect because stool being a dark green color is not a finding that the nurse should report to the provider. Stool from an ileostomy can be dark green, brown, or yellow depending on the diet and fluid intake of the client.
Choice B: This is incorrect because stoma being a cherry red color is not a finding that the nurse should report to the provider. Stoma from an ileostomy should be moist and pink or red, indicating adequate blood supply and healing.
Choice C: This is incorrect because stool containing scant red blood is not a finding that the nurse should report to the provider. Stool from an ileostomy can contain small amounts of blood due to irritation or inflammation of the bowel mucosa.
Choice D: This is correct because stoma retracting into the abdominal wall is a finding that the nurse should report to the provider. Stoma from an ileostomy should protrude slightly above the skin level, allowing for proper drainage and appliance fitting. Stoma retraction can indicate ischemia, obstruction, or peritonitis.
Correct Answer is B
Explanation
Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.
Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.
Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.
Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.
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