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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I moved the television to my bedroom for background noise." Having a television in the bedroom can be disruptive to sleep because it can interfere with relaxation and contribute to increased screen time before bed.
Choice B Reason:
"I go to the 24-hour gym shortly before I go to bed." Exercising shortly before bedtime can stimulate the body and make it more difficult to fall asleep. It's generally recommended to finish exercise at least a few hours before bedtime.
Choice C Reason:
"I am eating dinner later in the evening." Eating a heavy meal or eating too close to bedtime can lead to discomfort and indigestion, making it harder to sleep. It's better to have dinner at least a few hours before bedtime.
Choice D Reason:
"I am going to bed at the same time every night." The statement "I am going to bed at the same time every night" indicates an understanding of sleep promotion because it reflects consistency in the client's sleep schedule. Maintaining a regular sleep schedule helps regulate the body's internal clock and promotes healthy sleep patterns.
Correct Answer is B
Explanation
b. This must be very frightening for you. Let's talk more about it.
It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.
Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated and may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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