Nokea
Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the joint's proximal and distal areas prevents strain during ROM.
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The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement?
- A. Assess the client's surgical dressing every two (2) hours.
- B. Do not allow the client to see the residual limb.
- C. Keep a large tourniquet at the client's bedside.
- D. Perform passive range-of-motion exercises to the right leg.
Correct Answer: A
Rationale: Frequent dressing assessment detects bleeding, a critical post-BKA risk. Hiding the limb is inappropriate, tourniquets are for emergencies, and ROM is premature in recovery.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can be given to the operation of the client's surgical wound is approximated.
- D. None of the above
Correct Answer: B
Rationale: Achieving 90-degree knee flexion is a key milestone post-knee arthroplasty, indicating sufficient joint mobility to discontinue the CPM machine. Pain and wound healing are important but less specific to CPM use.
The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention?
- A. T 99°F, HR 80, RR 20, and BP 128/76.
- B. Pain in the unaffected leg during dorsiflexion of the ankle.
- C. Bowel sounds heard intermittently in four quadrants.
- D. Diffuse, crampy abdominal pain.
Correct Answer: B
Rationale: Pain on dorsiflexion (Homans’ sign) suggests DVT, a serious post-TKR complication requiring immediate intervention. Normal vitals, bowel sounds, and abdominal pain are less urgent.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.