The nurse understands that the placement of a pillow under the knee of a client with a total knee replacement is contraindicated because it will:

Increase the pain level and need for medication.

encourage the development of a flexion contracture.

stop circulation to the extremity.

cause possible skin breakdown.

Answer and Explanation

The Correct Answer is B

A. While pain may increase if the knee is positioned improperly, the primary concern is the development of a contracture.

B. Placing a pillow under the knee after total knee replacement can promote a flexion contracture, which results in the inability to fully extend the knee. This is undesirable as it can limit mobility and function post-surgery.

C. The pillow does not stop circulation to the extremity directly.

D. A pillow under the knee is not typically associated with skin breakdown unless the client is immobile for extended periods, but the risk of contracture is a more immediate concern.

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Correct Answer is B

Explanation

A. Incontinence briefs are appropriate for overnight use but do not encourage independence in bladder management during the day.

B. Providing easy-to-remove clothing is a practical intervention that enhances the client's independence in managing toileting, especially if they have cognitive impairments. It ensures that the client can quickly respond to the urge to urinate.

C. Explaining the use of a call bell is helpful but may not be the most appropriate approach for a cognitively-impaired client who may forget or struggle with communication.

D. Asking the client every two hours if they need to urinate is helpful but may not be as effective as providing easy access to clothing for quick toileting.

A. Hypotension B. Heartburn C. Fever D. Gout

Correct Answer is C

Explanation

A. Hypotension is not associated with SLE exacerbation.

B. Heartburn is not a trigger for SLE flares.

C. Fever can indicate infection or inflammation, common triggers for SLE exacerbations.

D. Gout is unrelated to SLE exacerbation.

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The nurse understands that the placement of a pillow under the knee of a client with a total knee replacement is contraindicated because it will:

Nursing Test Bank

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