A nurse is caring for a patient who is postoperative following a total knee arthroplasty and is using a continuous passive motion (CPM) device.
What actions should the nurse take?
Elevate the head of the bed 45 degrees before starting the CPM device.
Instruct the patient to increase the degree of flexion as tolerated.
Ensure the frame joint is in a flexed position before placing the leg onto the device.
Ensure the knee joint is positioned over the CPM device frame joint.
The Correct Answer is D
Choice A rationale
Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.
Choice B rationale
Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.
Choice C rationale
Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.
Choice D rationale
Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Bulging skin around the stoma can be a sign of a hernia, but it’s not uncommon in the early postoperative period. It should be monitored, but it’s not typically a cause for immediate concern.
Choice B rationale
A stoma that protrudes 2 cm (0.8 in) above the abdominal wall is considered normal. The stoma should protrude above the skin to prevent stool from coming into contact with the skin, which can cause irritation and breakdown.
Choice C rationale
A stoma that is moist and beefy red is a sign of a healthy stoma. This indicates that the stoma has a good blood supply and is not ischemic or necrotic.
Choice D rationale
No fecal output from the stoma 24 hours after surgery could indicate a blockage or other complication and should be reported to the provider immediately.
Correct Answer is C
Explanation
Choice A rationale
Drinking contrast medium is not typically required for an esophagogastroduodenoscopy (EGD). Contrast media are often used in imaging studies such as CT scans or certain types of X- rays, not for EGD45.
Choice B rationale
Shaving the client from axillae to groin is not necessary for an EGD. This might be required for certain types of surgeries, but an EGD is a non-surgical procedure that involves inserting a flexible tube with a light and camera into the esophagus, stomach, and duodenum.
Choice C rationale
Ensuring the signed consent is in the medical record is crucial before any procedure, including an EGD45678. It is a legal and ethical requirement that ensures the client is informed about the procedure, its purpose, its risks and benefits, and any alternatives.
Choice D rationale
Administering a cleansing enema is not typically required for an EGD. While bowel preparation, such as using a laxative or enema, might be necessary before some procedures like a colonoscopy, it is not usually needed for an EGD45.
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