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:
"I moved the television to my bedroom for background noise." Having a television in the bedroom can be disruptive to sleep because it can interfere with relaxation and contribute to increased screen time before bed.
Choice B Reason:
"I go to the 24-hour gym shortly before I go to bed." Exercising shortly before bedtime can stimulate the body and make it more difficult to fall asleep. It's generally recommended to finish exercise at least a few hours before bedtime.
Choice C Reason:
"I am eating dinner later in the evening." Eating a heavy meal or eating too close to bedtime can lead to discomfort and indigestion, making it harder to sleep. It's better to have dinner at least a few hours before bedtime.
Choice D Reason:
"I am going to bed at the same time every night." The statement "I am going to bed at the same time every night" indicates an understanding of sleep promotion because it reflects consistency in the client's sleep schedule. Maintaining a regular sleep schedule helps regulate the body's internal clock and promotes healthy sleep patterns.
Correct Answer is A
Explanation
Choice A Reason:
A client who has a femur fracture and reports numbness of the toes. In the given scenario, the nurse should prioritize seeing the client with a femur fracture who reports numbness of the toes. Numbness in the toes may indicate compromised circulation or nerve damage, which can be a serious complication of a femur fracture. Addressing this issue promptly is crucial to prevent further complications.
Choice B Reason:
A client with cirrhosis and severe pruritus, while uncomfortable, does not require immediate intervention in the same way that a potential circulation issue does.
Choice C Reason:
A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable and not in immediate distress. The nurse can see this client after addressing the more urgent situation.
Choice D Reason:
A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be monitored closely for signs of bleeding, but the issue is not as urgent as the potential nerve or circulation problem in the client with a femur fracture and numbness of the toes.
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