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

raise the head of the bed to 30 to 45 degrees.

elevate the machine at the foot of the bed on one pillow.

set the proper flexion and extension limits.

keep the operated knee warm.

Answer and Explanation

The Correct Answer is C

A. Raise the head of the bed to 30 to 45 degrees.

While head elevation for comfort is acceptable, it is not the primary responsibility for CPM care.

B. Elevate the machine at the foot of the bed on one pillow.

The CPM machine should lie flat along the bed frame. Elevation on a pillow can cause misalignment or malfunction.

C. Set the proper flexion and extension limits.

The nurse must confirm that the machine is set according to the provider's orders for proper range of motion and to prevent injury.

D. Keep the operated knee warm.

While comfort is important, this is not a priority of CPM machine care and doesn't directly relate to its function.

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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.

A. using the spreader bar to turn the patient. B. protecting the cast from soiling. C. grasping the cast over the leg to help in turning. D. easing itching under the cast by scratching with a bent coat hanger. E. turning frequently to the prone position.

Correct Answer is ["B","E"]

Explanation

A. Using the spreader bar to turn the patient.

The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.

B. Protecting the cast from soiling.

Soiling the cast can lead to skin irritation and infection, especially in the perineal area.

C. Grasping the cast over the leg to help in turning.

This can cause pressure points or cast damage; turning should be done using proper support techniques.

D. Easing itching under the cast by scratching with a bent coat hanger.

This is unsafe and can cause skin injury or infection under the cast.

E. Turning frequently to the prone position.

Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.

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

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Naxlex Comprehensive Predictor Exams

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