After a total knee replacement, a client is on the postoperative ...

[ashley]

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry;
 
  and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
 
  a.
  Document the findings and monitor as prescribed.
  b.
  Increase the frequency of monitoring the client.
  c.
  Notify the surgeon or anesthesia provider immediately.
  d.
  Palpate the client's bladder or perform a bladder scan.

Question 2

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
 
  a. Assess the distal circulation in 30 minutes.
  b. Change the settings based on range of motion.
  c. Raise the lower siderail on the affected side.
  d. Remind the client to do quad-setting exercises.

[ntsoane kedibone]

Answer to Question 1

ANS: C
With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

Answer to Question 2

ANS: C
Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

[ashley]

TYSM

[cdmart10]

Thanks for the timely response, appreciate it