Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Palms only.

Using palms distributes pressure evenly and prevents indentations in the wet cast that could lead to pressure sores.

B. Palms and flat parts of fingers.

Using palms is safest; fingers can still create indentations if not careful.

C. Fingertips and flat parts of fingers.

Fingertips can leave dents in the soft plaster, which may cause pressure points and skin breakdown once the cast hardens.

D. Fingertips and palms.

Fingertips should be avoided entirely when handling a fresh cast.

A. Ask the client if she has been out of bed today. B. Ask the client to push her legs and feet against the nurse's palms. C. Check the client's pedal pulses and feet for edema. D. Ask the client how strong she feels today.

Correct Answer is B

Explanation

A. Ask the client if she has been out of bed today:

This gives some insight into activity level but doesn't objectively measure strength.

B. Ask the client to push her legs and feet against the nurse's palms:

This provides a direct, physical assessment of the client's lower extremity strength, which is essential before ambulation.

C. Check the client's pedal pulses and feet for edema:

These assessments are related to circulation, not muscular strength.

D. Ask the client how strong she feels today:

This is subjective and may not reflect actual muscle strength or ability to ambulate safely.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When handling a freshly applied plaster cast while assisting a patient from stretcher to bed, the nurse should handle the cast using:

Correct Answer is A

Explanation

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is B

Explanation

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

The nurse, in order to prevent the cast from chafing, will instruct the patient for home care to _______ the rough edges with adhesive tape.

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:

A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)

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.