A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn the CPM machine off while the client is eating.
Store the CPM machine on the floor when not in use.
Check the settings of the CPM machine every 12 hours.
Increase the range of motion rapidly when the CPM machine is used intermittently.
The Correct Answer is A
Choice A reason: This response is appropriate because it encourages the client to seek professional medical advice, ensuring they receive personalized recommendations based on their health status and needs. It also emphasizes the importance of a physical examination to rule out any contraindications or underlying health issues before starting any contraceptive method.
Choice B reason: Storing the CPM machine on the floor when not in use is not recommended as it can pose a tripping hazard and may not comply with safety standards. The machine should be stored properly according to the manufacturer's instructions to ensure safety and maintain the equipment's integrity.
Choice C reason: While barrier methods are a good option for preventing both pregnancy and sexually transmitted infections (STIs), suggesting a specific method without a full assessment of the client's needs and preferences is not ideal. It is better to involve a healthcare provider in the decision-making process.
Choice D reason: Increasing the range of motion rapidly when the CPM machine is used intermittently is not advised. Adjustments to the range of motion should be made gradually and according to the client's tolerance and the surgeon's orders. Rapid increases can cause pain and may hinder the healing process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.
Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.
Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.
Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.
Correct Answer is D
Explanation
Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.
Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.
Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.
Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.
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