A nurse is planning care for a client who is 6 hr. postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?
Apply warm, moist packs to the surgical site.
Massage the lower leg in smooth, long strokes.
Place a pillow under the client's surgical knee.
Use the continuous passive-motion machine intermittently.
The Correct Answer is D
Choice A Reason:
Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.
Choice B Reason:
Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.
Choice C Reason:
When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).
Choice D Reason:
Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance. CPM is typically initiated early postoperatively, often within the first 24 hours after surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A. Applying water-soluble lubricant to the site is not typically necessary for routine site care. It may be used during the initial insertion of the tube or when changing the tube, but it's not part of routine site care.
Choice B Reason:
B. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy tube. Securing the tube to the cheek may cause irritation or discomfort for the child and is not a secure method to prevent dislodgment.
Choice C Reason:
C. Attaching an extension tube to the site's opening prior to use may be necessary for feeding or medication administration, but it is not specific to site care. Site care primarily involves cleaning and inspecting the site and ensuring that the tube is secure.
Choice D Reason:
Securing the tubing to the child's abdomen is correct. When providing site care for a child with a gastrostomy enteral tube, it's essential to ensure that the tube is secured properly to prevent accidental dislodgment. Therefore, the nurse should secure the tubing to the child's abdomen using appropriate medical tape or a securement device.
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