A nurse is reinforcing discharge teaching to a client following arthroscopic (joint) surgery.
To prevent postoperative complications which of the following actions should be reinforced during the teaching of Continuous passive motion (CPM)?
Let the patient lift the machine onto the bed.
Tell the patient CPM will not hurt at all.
The patient really doesn't need to do CPM exercises.
Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
The Correct Answer is D
Choice A rationale:
Allowing the patient to lift the CPM machine onto the bed is not a safe practice. Arthroscopic surgery may result in limited mobility and discomfort for the patient. Lifting heavy equipment could potentially strain the surgical site or lead to injury.
Choice B rationale:
Telling the patient that CPM will not hurt at all is not accurate. While CPM is a passive motion technique aimed at preventing joint stiffness, some discomfort or mild pain may be experienced, especially during the initial sessions. Managing the patient's pain is essential to ensure compliance with the CPM exercises.
Choice C rationale:
Suggesting that the patient does not need to do CPM exercises is incorrect. CPM exercises are often prescribed after joint surgery to prevent joint stiffness, improve circulation, and aid in recovery. Discouraging the patient from participating in these exercises would be detrimental to their postoperative outcome.
Choice D rationale:
Administering an opioid analgesic to the client 30 minutes before initiating CPM exercises is the correct choice. CPM exercises can be uncomfortable for some patients, especially in the initial stages, and providing adequate pain relief before starting the exercises promotes patient comfort and compliance. It helps ensure that the patient can perform the exercises effectively without undue pain, reducing the risk of complications and promoting a successful recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale:
Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.
Choice B rationale:
The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.
Choice C rationale:
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.
Choice D rationale:
A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.
Choice E rationale:
Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.
Choice F rationale:
Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.
Choice G rationale:
A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.
Correct Answer is C
Explanation
Choice A rationale:
Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.
Choice B rationale:
Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.
Choice C rationale:
Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.
Choice D rationale:
Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.
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