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The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat

respiratory alkalosis.

atelectasis.

hypostatic pneumonia.

low oxygen saturation.

Answer and Explanation

The Correct Answer is C

A. Respiratory alkalosis.

Respiratory alkalosis is caused by hyperventilation, not by immobility. Deep breathing won't target this issue.

B. Atelectasis.

While deep breathing can help prevent atelectasis (lung collapse), the primary concern in immobilized patients is hypostatic pneumonia.

C. Hypostatic pneumonia.

Deep breathing promotes lung expansion and mobilizes secretions, helping prevent hypostatic pneumonia, which results from stasis of secretions due to immobility.

D. Low oxygen saturation.

While deep breathing may improve oxygen saturation, the primary goal is to prevent atelectasis and pneumonia.

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

Explanation

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.

A. "Keep your head straight and turn it as far as possible to either side." B. "Move your head from the upright position back as far as you can." C. "Move your head so that your chin rests on your chest." D. "Move your head laterally towards your right and left shoulder."

Correct Answer is B

Explanation

A. "Keep your head straight and turn it as far as possible to either side."

This is rotation, not hyperextension.

B. "Move your head from the upright position back as far as you can."

This describes hyperextension, which is the movement of the head beyond the neutral upright position.

C. "Move your head so that your chin rests on your chest."

This is flexion, not hyperextension.

D. "Move your head laterally towards your right and left shoulder."

This describes lateral flexion, not hyperextension.

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The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat

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Naxlex Comprehensive Predictor Exams

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.

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

Explanation

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

Correct Answer is B

Explanation

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