Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby.
Select all the options that need to be reported to the responsible nurse.
Mr. Milby states his pain level is a 0/10
Head of bed is elevated 45 degrees
Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion.
all side rails on Mr. Milby's bed are down
the knee dressing is loose and not adhering on all sides
the machine is set to 45 degrees of flexion
Correct Answer : B,C,D,E
A. Mr. Milby states his pain level is a 0/10
This indicates good pain control, which is expected and desired postoperatively.
B. Head of bed is elevated 45 degrees
Elevation this high may cause improper alignment and interfere with the machine’s function. Typically, HOB should be no more than 20-30 degrees during CPM use.
C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion
This could indicate excessive tension on the wound or early signs of complications like swelling or dehiscence.
D. All side rails on Mr. Milby’s bed are down
This is a safety hazard. At least one or two side rails should be up during machine use to prevent falls.
E. The knee dressing is loose and not adhering on all sides
Loose dressings may indicate poor wound protection and risk for infection or wound exposure.
F. The machine is set to 45 degrees of flexion
This is per the physician’s order and indicates proper settings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Turn their foot and leg away from their other leg
This movement is called external rotation, not hyperextension.
B. Move their leg forward and up
This action is flexion of the hip.
C. Move their leg medially toward their other leg
This describes adduction, moving the limb toward the body's midline.
D. Move their leg behind their body
Hyperextension of the hip involves moving the leg backward beyond the normal range of extension.
Correct Answer is ["A","B","C","D"]
Explanation
A. Loss of calcium from bone matrix
Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.
B. Stasis of respiratory secretions
Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.
C. Increased cardiac workload
Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.
D. Decreased circulation from pressure
Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.
E. Increased mental activity
Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.
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