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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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hold the crutches on your unaffected side when preparing to sit in a chair

This helps maintain balance and control while transitioning from standing to sitting.

B. Hold the crutches 9 inches in front and to the side of each foot

The correct placement is approximately 6 inches (not 9) in front and 6 inches to the side of each foot for stability.

C. Lean on the crutches to support your body weight when standing

Weight should be supported by the hands on the handgrips, not the axillae, to avoid nerve injury (e.g., brachial plexus damage).

D. Fully extend your arms when holding onto the hand grips

The elbows should be slightly flexed (about 20-30 degrees) to allow proper support and shock absorption.

A. Muscle atrophy B. Venous pooling C. Urinary stasis D. Increased depth of respirations E. Increased metabolic rate

Correct Answer is ["A","B","C"]

Explanation

A. Muscle atrophy

Lack of movement leads to wasting of muscle tissue over time, a common consequence of immobility.

B. Venous pooling

Immobility causes reduced venous return, leading to venous stasis or pooling, increasing the risk of DVT.

C. Urinary stasis

Lying flat for extended periods contributes to bladder emptying issues, increasing risk for UTIs and renal calculi.

D. Increased depth of respirations

Immobility leads to shallow breathing and reduced lung expansion, not deeper respirations.

E. Increased metabolic rate

Immobility generally results in a decreased metabolic rate due to lower energy needs.

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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

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

Correct Answer is ["A","B","C"]

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?

A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

A 46-year-old male was injured in an industrial accident and has suffered a fractured left leg and left wrist. His wrist is treated with a cast and the leg is placed in skeletal traction. Because of immobilization of his leg, the patient is at risk for (Select all that apply.)

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

The nurse working with immobilized patients understands that monitoring for reports of pain with urination, changes in urination, and assessing fro frequency is essential in order to determine if an unwanted urinary problem is arising from her patient being immobile.

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?