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The nurse working in the medical-surgical unit, is caring for a patient that had knee surgery. She notices that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. She should

reassess the area in 8 hours

stop the machine and notify the primary care provider

increase the angle of the flexion of the joint to change the pressure on the heel

pad the portion of the machine that the heel rests on

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

D. True

Air-fluidized beds use tiny beads under a permeable sheet to reduce pressure and support patients at risk for pressure ulcers. Although the beads are ceramic or coated plastic, not metal, the core concept is accurate for most clinical purposes.

A. Move overbed tables away from the bed. B. Instruct the clients to use the call light. C. Perform client checks every 4 hr. D. Keep the clients' rooms dark. E. Place a fall risk wristband on each of the clients.

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.

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The nurse working in the medical-surgical unit, is caring for a patient that had knee surgery. She notices that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. She should

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Please indicate whether the following statement is true or false. Air fluidized beds use tiny metal beads that are contained within the bed under a flexible, air-permeable filter sheet.

Correct Answer is D

Explanation

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

Please indicate whether the following statement is true or false. A nurse working on the orthopedic floor understands that a gastrointestinal assessment should be done every three days.

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