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What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: The CPM machine gently flexes and extends the knee post-arthroplasty to restore joint function and prevent stiffness, not primarily to strengthen muscles, reduce swelling, or relieve pain.
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The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.
The home health nurse is caring for clients who had a THR through the posterior surgical approach 2 weeks ago. It is most important for the nurse to intervene immediately for which client?
- A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
- B. After a THR the client may sit at 90 degrees.
- C. After a THR the client may lie supine.
- D. After a THR the client may be up. However, this client should be wearing shoes or gripper socks or slippers to prevent a fall.
Correct Answer: A
Rationale: A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority?
- A. Urinalysis and culture and sensitivity
- B. Blood alcohol level and toxicology screen
- C. Computed tomography (CT) scan of the pelvis
- D. Give two units of cross-matched whole blood
Correct Answer: D
Rationale: D. Significant blood loss occurs because the pelvis is a highly vascular area. A type and cross-match must be completed prior to administering blood, which takes time.
The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Prepare the client by removing all metal objects.
- B. Inject the contrast into the intravenous site.
- C. Administer a sedative to the client to decrease anxiety.
- D. Explain why the client cannot have any breakfast.
Correct Answer: A
Rationale: Removing metal objects is a safe UAP task, ensuring MRI safety. Contrast injection, sedation, and explanations require nursing judgment.
Which statement by the nurse provides the best explanation about the purpose of antiembolism stockings?
- A. Antiembolism stockings prevent blood from pooling in the legs.
- B. Antiembolism stockings reduce blood flow to the exercises.
- C. Antiembolism stockings keep the blood pressure lower in the legs.
- D. Antiembolism stockings keep the blood vessels constricted.
Correct Answer: A
Rationale: Antiembolism stockings apply graduated compression to promote venous return, preventing blood pooling and reducing the risk of deep vein thrombosis in immobile clients. The other options are inaccurate.