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The nurse working in the medical-surgical unit, is caring for a patient that had knee surgery. She notices that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. She should

reassess the area in 8 hours

stop the machine and notify the primary care provider

increase the angle of the flexion of the joint to change the pressure on the heel

pad the portion of the machine that the heel rests on

Answer and Explanation

The Correct Answer is B

A. Reassess the area in 8 hours

Delaying action may result in wound dehiscence or further tissue damage.

B. Stop the machine and notify the primary care provider

Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.

C. Increase the angle of the flexion of the joint to change the pressure on the heel

Increasing the angle may worsen the wound separation and increase pressure on the incision.

D. Pad the portion of the machine that the heel rests on

Padding may prevent pressure injury but does not address the wound issue or tightness from movement.

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Correct Answer is D

Explanation

A. Hyperextension

Hyperextension refers to bending backward beyond the normal range.

B. Lateral flexion

Lateral flexion involves bending the neck to the side, ear toward shoulder.

C. Rotation

Rotation refers to turning the head side-to-side (e.g., shaking head “no”).

D. Flexion

Touching the chin to the chest is flexion of the neck-bending forward.

A. cover the pin with several gauze pads and tape securely. B. assure the patient that such drainage is expected. C. notify the charge nurse of possible infection. D. wipe off drainage with a damp wash cloth.

Correct Answer is B

Explanation

A. Cover the pin with several gauze pads and tape securely:

This may trap moisture and increase infection risk. Pin sites need to be monitored and cleaned regularly.

B. Assure the patient that such drainage is expected:

Serous drainage is a normal finding after pin insertion. Reassurance is appropriate unless signs of infection are present.

C. Notify the charge nurse of possible infection:

This may be premature without signs of infection (e.g., purulent drainage, redness, fever).

D. Wipe off drainage with a damp wash cloth:

This is not a sterile technique and may introduce infection. Pin site care should follow sterile protocol.

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The nurse working in the medical-surgical unit, is caring for a patient that had knee surgery. She notices that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. She should

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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