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Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby.
Select all the options that need to be reported to the responsible nurse.

Mr. Milby states his pain level is a 0/10

Head of bed is elevated 45 degrees

Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion.

all side rails on Mr. Milby's bed are down

the knee dressing is loose and not adhering on all sides

the machine is set to 45 degrees of flexion

Answer and Explanation

Correct Answer : B,C,D,E

A. Mr. Milby states his pain level is a 0/10

This indicates good pain control, which is expected and desired postoperatively.

B. Head of bed is elevated 45 degrees

Elevation this high may cause improper alignment and interfere with the machine’s function. Typically, HOB should be no more than 20-30 degrees during CPM use.

C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion

This could indicate excessive tension on the wound or early signs of complications like swelling or dehiscence.

D. All side rails on Mr. Milby’s bed are down

This is a safety hazard. At least one or two side rails should be up during machine use to prevent falls.

E. The knee dressing is loose and not adhering on all sides

Loose dressings may indicate poor wound protection and risk for infection or wound exposure.

F. The machine is set to 45 degrees of flexion

This is per the physician’s order and indicates proper settings.

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Correct Answer is B

Explanation

A. Cover the pin with several gauze pads and tape securely:

This may trap moisture and increase infection risk. Pin sites need to be monitored and cleaned regularly.

B. Assure the patient that such drainage is expected:

Serous drainage is a normal finding after pin insertion. Reassurance is appropriate unless signs of infection are present.

C. Notify the charge nurse of possible infection:

This may be premature without signs of infection (e.g., purulent drainage, redness, fever).

D. Wipe off drainage with a damp wash cloth:

This is not a sterile technique and may introduce infection. Pin site care should follow sterile protocol.

A. dry and dirty. B. moist and pink. C. moist and white D. dry and greenish.

Correct Answer is A

Explanation

A. Dry and dirty

Skin under a cast is typically dry, flaky, and appears dirty due to the accumulation of dead skin cells and lack of exposure to air and water.

B. Moist and pink

Moist and pink skin suggests healthy, well-hydrated tissue, which is not typical after cast removal.

C. Moist and white

Moist and white skin may indicate maceration, which can occur under wet dressings, not a dry cast.

D. Dry and greenish

Green discoloration is not a normal finding and may suggest infection, which is not expected under a dry cast unless there were complications.

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Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby. Select all the options that need to be reported to the responsible nurse.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby.
Select all the options that need to be reported to the responsible nurse.