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The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
- A. Stabilize the knee joint during ambulation
- B. Promote knee flexion
- C. Reduce post-surgical swelling
- D. Prevent blood clots
Correct Answer: B
Rationale: The primary purpose of a CPM device is to promote knee flexion and range of motion post-surgery, aiding recovery. It doesn't stabilize during ambulation, primarily reduce swelling, or prevent clots.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 62-year-old female client.
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Triage Note
1211: The client was brought to the ED by her neighbor, who was concerned about her increasing pain and immobility. The client's neighbor reported that the client called her a few hours ago, asking her to go to the ED because of increasing pain and the inability to perform her activities of daily living. History of osteoporosis, hypertension, and gout. She reports that she recently started seeing a rheumatologist because of persistent fatigue, low-grade fevers, and lack of appetite. Vital signs: T 99.7° F (37.6° C), P 82, RR 16, BP 134/76, pulse oximetry reading 98% on room air. Pain rated 7/10 on the Numerical Rating Scale, which is described as throbbing of both feet, especially in her toes. She also reports having stiffness in her wrists and fingers that starts in the morning and persists throughout the day. Triage assessment: the client is alert and fully oriented to person, place, and situation. Peripheral pulses 2+. Clear lung sounds bilaterally. Swollen, errythemic toes that are warm and tender to touch. She does not recall her weight but reports significant weight loss over the past three months.
For each assessment finding below, click to specify if the finding is consistent with the disease process of osteoarthritis, acute gout flare, or rheumatoid arthritis. Each finding may support more than 1 disease process.
- A. Low-grade fever
- B. Weight loss
- C. Redness and warmth of the affected joint
- D. Morning joint stiffness in the wrists that lasts throughout the day
- E. Pain with movement in the affected joint
- F. Reduced range of motion in the affected joint
- G. Pain level
Correct Answer: A: Rheumatoid Arthritis, Acute Gout Flare, B: Rheumatoid Arthritis, C: Rheumatoid Arthritis, Acute Gout Flare, D: Rheumatoid Arthritis, E: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, F: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, G: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare
Rationale: Seen in inflammatory conditions; not typical in osteoarthritis. Chronic systemic inflammation may lead to unintentional weight loss. Indicates joint inflammation; osteoarthritis does not usually present with warmth or redness. Stiffness >1 hour, especially in small joints, is classic for RA. Movement worsens pain in all these conditions, though the cause differs. All limit ROM due to stiffness, inflammation, or damage. Pain is a shared feature, though severity and timing vary.
The nurse is caring for a client six hours postoperative following a below-knee amputation (BKA). Which of the following assessment findings requires follow-up?
- A. Restlessness
- B. Blood pressure of 140/78 mmHg
- C. Pulse rate of 89 bpm
- D. Hypoactive bowel sounds in all four quadrants
Correct Answer: A
Rationale: Restlessness can be a sign of pain, anxiety, or hypoxia, all of which require follow-up in a postoperative client. The blood pressure and pulse rate are within normal limits, and hypoactive bowel sounds are expected shortly after surgery due to anesthesia and reduced gastrointestinal motility.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.
The nurse is caring for a client who has a fiberglass cast that has just been applied to their left arm due to a humerus fracture. Three hours later, the client complains of numbness in his fingers, and says his fingers 'have become pale.' What is the nurse's most appropriate action?
- A. Reassure the client that this is just a normal occurrence after having a cast.
- B. Ask the client to clench his fist frequently.
- C. Remove the cast immediately.
- D. Notify the primary healthcare provider (PHCP).
Correct Answer: D
Rationale: Numbness and pallor in the fingers are signs of potential compartment syndrome or impaired circulation, which are serious complications. The most appropriate action is to notify the primary healthcare provider immediately for further evaluation and intervention. Reassuring the client or asking them to clench their fist does not address the urgency, and removing the cast is not within the nurse's scope without a provider's order.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.