A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn off the CPM machine during mealtime.
Maintain the client's affected hip in an externally rotated position.
Instruct the client how to adjust the CPM settings for comfort.
Store the CPM machine under the client's bed when not in use.
The Correct Answer is A
- A. Correct. The nurse should turn off the CPM machine during mealtime, as it can interfere with the client's ability to eat and drink comfortably. The nurse should also turn off the CPM machine when transferring or repositioning the client, or when performing wound care or other interventions on the affected leg.
- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position, as external rotation can cause malalignment of the prosthesis and impair healing. The nurse should use pillows or wedges to support the leg and prevent rotation or abduction of the hip joint.
- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings, as this can compromise the prescribed range of motion and speed of the device. The nurse should follow the provider's orders and check with them before making any changes to the CPM settings. The nurse should also monitor the client's pain level and administer analgesics as needed to facilitate compliance with the therapy.
- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this can pose a safety hazard and damage the equipment. The nurse should place the CPM machine on a stable surface near the bed and ensure that it is plugged into a grounded outlet and has adequate battery backup in case of power failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While providing end-of-life education is important, it is not a specific requirement under the Patient Self-Determination Act. The act primarily focuses on ensuring that patients' wishes regarding medical treatment and interventions are respected through advance directives.
Choice B rationale:
Documenting in the client's medical record if the client has advance directives is a requirement under the Patient Self-Determination Act. This documentation ensures that healthcare providers are aware of the patient's preferences regarding medical treatment, especially in end-of-life situations. Advance directives may include living wills or durable power of attorney for healthcare, allowing patients to express their choices regarding medical interventions and appointing someone to make decisions on their behalf if they are unable to do so.
Choice C rationale:
Providing the client with a list of eligible individuals who can serve as a health care proxy is not a requirement under the Patient Self-Determination Act. While it can be helpful, the act primarily emphasizes documenting and respecting the patient's existing advance directives.
Choice D rationale:
Ensuring the client has an attorney for assistance with end-of-life documents is not a requirement under the Patient Self-Determination Act. While legal advice can be beneficial, the act primarily focuses on healthcare providers' responsibilities in documenting and respecting patients' advance directives.
Correct Answer is C
Explanation
Choice A rationale:
Tightening the tubing connections may be necessary if there is a leak in the ventilator system, but it does not address the high-pressure alarm issue. The nurse needs to address the immediate alarm situation first.
Choice B rationale:
Requesting insertion of a tracheostomy tube is not the appropriate action for a high-pressure alarm on the ventilator. Tracheostomy tube insertion is a significant procedure that is not indicated solely based on a high-pressure alarm.
Choice C rationale:
Suctioning the client's airway is the correct action for a high-pressure alarm on the ventilator. The alarm indicates an obstruction in the airway, and suctioning can help clear any secretions or blockages, allowing the client to breathe more effectively.
Choice D rationale:
Looking for a leak in the tube's cuff may be necessary if the high-pressure alarm persists after suctioning and checking connections. Identifying and repairing any leaks can prevent further issues with ventilation. However, immediate action should be taken to clear the airway first, as indicated by suctioning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.