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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

Answer and Explanation

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.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Elevate the foot:

Elevation helps reduce swelling by promoting venous return.

B. Encourage range-of-motion exercises of the foot:

Movement should be limited until the injury is evaluated to prevent further damage.

C. Provide the client with a light snack:

This can be appropriate if there are no contraindications, especially if the client has been waiting and is hungry. It doesn’t worsen the injury and supports comfort.

D. Apply a compression bandage:

Compression helps reduce swelling and provides support to the injured joint.

E. Apply ice to the ankle:

Ice reduces inflammation and helps with pain management during the acute phase of a soft-tissue injury.

A. Muscle atrophy B. Venous pooling C. Urinary stasis D. Increased depth of respirations E. Increased metabolic rate

Correct Answer is ["A","B","C"]

Explanation

A. Muscle atrophy

Lack of movement leads to wasting of muscle tissue over time, a common consequence of immobility.

B. Venous pooling

Immobility causes reduced venous return, leading to venous stasis or pooling, increasing the risk of DVT.

C. Urinary stasis

Lying flat for extended periods contributes to bladder emptying issues, increasing risk for UTIs and renal calculi.

D. Increased depth of respirations

Immobility leads to shallow breathing and reduced lung expansion, not deeper respirations.

E. Increased metabolic rate

Immobility generally results in a decreased metabolic rate due to lower energy needs.

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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.

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A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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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.

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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.