Nokea
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: CPM promotes joint mobility and prevents stiffness post-arthroplasty.
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Which finding should the nurse report as a sign of increased intracranial pressure (ICP)?
- A. While an increasing temperature may be associated with ICP, it may also be due to an infection. It is more important for the nurse to report the widened pulse pressure as a sign of increased ICP.
- B. A widened pulse pressure (increased systolic BP and a decreased diastolic BP) is one of the signs of Cushing's triad and is indicative of ICP.
- C. Bradycardia (not tachycardia) is associated with ICP.
- D. An increased systolic BP (not decreased systolic BP) is another sign of Cushing's triad.
Correct Answer: B
Rationale: Widened pulse pressure is a hallmark of Cushing's triad, indicating increased ICP.
The nurse teaches the trainers that adolescent soccer players are at increased risk for which abnormality?
- A. Varus knee deformities
- B. Valgus knee deformities
- C. Varus ankle deformities
- D. Valgus ankle deformities
Correct Answer: A
Rationale: Adolescent soccer players are at risk for varus knee deformities due to repetitive stress on the knees.
Which foods should the nurse recommend to a client when discussing sources of dietary calcium?
- A. Yogurt and dark-green, leafy vegetables.
- B. Oranges and citrus fruits.
- C. Bananas and dried apricots.
- D. Wheat bread and bran.
Correct Answer: A
Rationale: Yogurt and dark-green leafy vegetables (e.g., kale) are rich in calcium, supporting bone health. Other options have minimal calcium content.
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take?
- A. Take no action because this is the correct procedure for transferring a client.
- B. Instruct the UAPs not to use a transfer board when moving the client.
- C. Tell the UAPs to use the bed scale sling to move the client to the chair.
- D. Request the UAPs to stop and come to the nurse’s station immediately.
Correct Answer: A
Rationale: Using a transfer board is safe and appropriate for bed-to-wheelchair transfers; no action is needed. Other options are incorrect or unsafe.
When the nurse is documenting the client's progress while using a continuous passive motion (CPM) machine, which assessment data are essential to include?
- A. Degree of flexion, number of cycles, and condition of the incision
- B. Degree of flexion, number of cycles, and amount of time the client used the machine
- C. Degree of flexion, number of cycles, and characteristics of drainage from the wound
- D. Degree of flexion, number of cycles, and presence and quality of arterial pulses
Correct Answer: B
Rationale: Documenting the degree of flexion, number of cycles, and time used on the CPM machine tracks progress in restoring joint function. Incision condition, drainage, or pulses are monitored separately.