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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Move overbed tables away from the bed
Overbed tables should be kept within reach so clients don’t overextend or stand unsafely to access them.
B. Instruct the clients to use the call light
Reinforcing use of the call light promotes help-seeking before unsafe mobility attempts.
C. Perform client checks every 4 hr
High-risk clients should be checked more frequently, typically every hour or two, especially overnight.
D. Keep the clients' rooms dark
Poor lighting increases fall risk. A night light should be used.
E. Place a fall risk wristband on each of the clients
Fall risk wristbands alert staff and ensure precautions are taken consistently.
Correct Answer is B
Explanation
A. Reassess the area in 8 hours
Delaying action may result in wound dehiscence or further tissue damage.
B. Stop the machine and notify the primary care provider
Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.
C. Increase the angle of the flexion of the joint to change the pressure on the heel
Increasing the angle may worsen the wound separation and increase pressure on the incision.
D. Pad the portion of the machine that the heel rests on
Padding may prevent pressure injury but does not address the wound issue or tightness from movement.
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