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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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Locks the hydraulic valve before attaching the sling to the lift

The hydraulic valve must be unlocked to adjust height and should only be locked after the client is securely attached and raised. Locking it before attaching the sling may indicate improper procedure or reduced safety during lifting.

B. Leaves the bed in the lowest position throughout the procedure

Leaving the bed low can be safe depending on facility protocol and prevents injury if the client or staff lose balance.

C. Raises the head of the bed to a sitting position just before the transfer

Elevating the head of the bed helps the client into a functional sitting position, making sling placement and transfer easier and safer.

D. Places a removable cover over the sling

A removable cover can enhance comfort and hygiene, especially if the sling is shared.

A. hydrotherapy B. petal C. bivalve D. splint

Correct Answer is B

Explanation

A. hydrotherapy

Hydrotherapy involves water treatment, not related to smoothing cast edges.

B. petal

Petaling is the technique of applying smooth strips of tape (usually in a petal shape) over rough edges to prevent skin irritation.

C. bivalve

Bivalving is when a cast is cut into two halves, typically to relieve pressure—not to smooth edges.

D. splint

A splint is a temporary immobilizing device, not related to the care of cast edges.

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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

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Naxlex Comprehensive Predictor Exams

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)

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 patient who fractured a leg several weeks ago is scheduled for cast removal after he returns home. The nurse should explain to the patient to expect the skin underneath the cast to appear:

The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.

A nurse is observing a patient in a skilled nursing facility using a walker. The nurse concludes that the walker is at proper height if the patient's elbows are bent to which angle while the patient is upright and grasping the handgrips?

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 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 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.)