A nurse is planning care for a client who is 6 hr. postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?
Apply warm, moist packs to the surgical site.
Massage the lower leg in smooth, long strokes.
Place a pillow under the client's surgical knee.
Use the continuous passive-motion machine intermittently.
The Correct Answer is D
Choice A Reason:
Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.
Choice B Reason:
Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.
Choice C Reason:
When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).
Choice D Reason:
Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance. CPM is typically initiated early postoperatively, often within the first 24 hours after surgery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Contact precautions are not sufficient for tuberculosis (TB), which is an airborne infection. Instead, airborne precautions should be initiated.
Choice B Reason:
Increasing the client's daily intake of vitamin D may be considered as a complementary measure to support the immune system.
Choice C Reason:
Performing tuberculin skin testing (TST) is a diagnostic test for TB but is typically not included in the plan of care for a newly admitted client with confirmed TB.
Choice D Reason:
Placing the client in a positive-pressure isolation room is not the recommended isolation method for clients with TB. Negative-pressure isolation rooms help prevent the spread of infectious airborne diseases like TB.
Correct Answer is D
Explanation
Choice A Reason:
Positioning the knot of the rope at the top of the pulley is incorrect. The knot should be placed at the foot of the bed to ensure proper traction.
Choice B Reason:
Removing the weights for 20 minutes without a healthcare provider's order is not appropriate. If the client experiences severe pain, the nurse should assess the client, evaluate the traction system, and notify the healthcare provider if necessary.
Choice C Reason:
Applying 6.8 kg (15 lb) of weight for use in traction is not the standard practice. The amount of weight used in Buck's traction varies depending on the healthcare provider's orders and the client's specific condition. The nurse should follow the healthcare provider's orders regarding the amount of weight to apply.
Choice D Reason:
Compare bilateral pedal pulses. When caring for a client with Buck's traction, it is essential to regularly assess the circulation to the extremity in traction. Comparing bilateral pedal pulses helps the nurse determine if there are any circulation issues in the affected leg. If the client's circulation is compromised, it can lead to complications such as deep vein thrombosis (DVT) or compartment syndrome.
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