Chapter 37
Maintain bed rest with the head of the bed at 20 degrees.
A client who was in a motor vehicle crash is diagnosed with a stable T7 spinal fracture with no neurologic deficits. Which nursing intervention should the nurse implement? · Maintain bed rest with the head of the bed at 20 degrees. · Sit the client upright in a padded chair for meals. · Maintain NPO (nothing by mouth) status for surgical repair. · Withhold opioid pain medication to prevent ileus.
Dry a wet fiberglass cast thoroughly to avoid skin problems
The nurse teaching the client with a cast about home care includes which instruction? · Keep the cast below heart level · Fix a broken cast by applying tape · Cover the cast with plastic or rubber · Dry a wet fiberglass cast thoroughly to avoid skin problems
· Instruct the client to avoid internal rotation of the leg.
Which intervention should the nurse implement with the client who has undergone a hip replacement? · Adduct the legs by placing a pillow between the legs. · Instruct the client to avoid internal rotation of the leg. · Have the client bend forward to rise from the chair. · Place the client in high Fowler's position for meals.
Exploring factors related to the client's home environment
A 68-year-old female client who had a below-the-knee amputation is to be discharged because her healing is almost complete. Which of the following would be most important for the nurse to discuss with this client? · Exploring factors related to the client's home environment · Urging her to keep the affected limb in an elevated position · Advising the client to avoid red meat · Educating the client about the effects of menopause
Sharp and piercing
A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain? · A dull, deep, boring ache · Sore and aching · Sharp and piercing Similar to "muscle cramp
Applying heat
A client comes to the clinic 2 days after sustaining a sprain to the left ankle. What intervention can the nurse encourage the client to perform that will help improve circulation? · Active range-of-motion exercises · Take nonsteroidal anti-inflammatory drugs · Applying cold compresses · Applying heat
Use of isometric exercises
A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm? · Proper use of a sling · Use of isometric exercises · Abduction and adduction of the shoulder · Repositioning the arm in the cast
Closed reduction
A client was playing softball and dislocated four fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as? · Open reduction · Closed reduction · External fixation · Open reduction with internal fixation
· Apply lotions and take warm baths or soaks.
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem? · Avoid exposure to direct sunlight. · Scrub the area vigorously to remove the crust. · Consult a skin specialist. · Apply lotions and take warm baths or soaks.
· Hypovolemic shock
A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern for this patient? · Infection · Hypovolemic shock · Knee and hip dislocation · Pain resulting from muscle spasm
Application of a cast
A physician writes a prescription to discontinue skeletal traction on an orthopedic client. The nurse should anticipate what subsequent intervention? · Application of a walking boot · Application of a cast · Education on how to use crutches · Passive range of motion exercises
Arterial blood gases
A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on this client? · Electrocardiogram · Arterial blood gases · Electrolyte assessment · Abdominal ultrasound
Distal radius
Colles fracture occurs in which area? · Elbow · Clavicle · Humeral shaft · Distal radius
· Assessing the left leg
Emergency medical technicians transport a client to the emergency department and inform the nurse that the client fell from a two-story building. The comatose client has a large contusion on the left side of the chest, a hematoma in the left parietal area, and a compound fracture of the left femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest priority? · Assessing the left leg · Assessing the pupils · Assessing level of consciousness (LOC) · Placing the client in Trendelenburg's position
Lack of distal tissue perfusion
Pulselessness, a very late sign of compartment syndrome, may signify · Venous congestion · Lack of distal tissue perfusion · Nerve involvement · Diminished arterial perfusion
Impacted
Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture? · Impacted · Compression · Comminuted · Greenstick
Excision of damaged joint fibrocartilage
The client is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure? · Incision and diversion of the muscle fascia · Replacement of one of the articular surfaces of a joint · Replacement of knee with artificial joint · Excision of damaged joint fibrocartilage
Dislocation of the hip
The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication? Contracture of the hip Dislocation of the hip Re-fracture of the hip Avascular necrosis of the hip
Femoral neck.
The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: · Trochanteric region. · Shaft of the femur. · Femoral neck. · Condylar area.
Fat embolism syndrome
The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has sustained a fracture. The nurse suspects which complication? · Reflex sympathetic dystrophy syndrome · Fat embolism syndrome · Compartment syndrome · Hypovolemic shock
Do not flex the hip more than 90 degrees.
The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? · Do not flex the hip more than 120 degrees. · Do not flex the hip more than 30 degrees. · Do not flex the hip more than 90 degrees. · Do not flex the hip more than 60 degrees.
Elevate the affected area.
The primary nursing intervention that will control swelling while treating a musculoskeletal injury is: · Apply cold (moist or dry). · Apply an elastic compression bandage. · Elevate the affected area. · Immobilize the injured area.
Educate the client on cast care and complications
What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast? · Prepare the client for cast application · Assess for neurovascular compromise · Provide effective pain control · Educate the client on cast care and complications
Neurovascular compromise
When caring for a client with a fracture, what assessment would take priority? · Altered kidney function · Cardiac problems · Hormonal imbalances · Neurovascular compromise
Chlorhexidine
Which cleansing solution is the most effective for use in completing pin site care? · Alcohol · Chlorhexidine · Hydrogen peroxide · Betadine
Strain
Which term refers to an injury to ligaments and other soft tissues surrounding a joint? · Sprain · Strain · Subluxation · Dislocation
Risk for Ineffective Peripheral Tissue Perfusion
While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client?
"Elevating the leg might lead to a flexion contracture."
A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? · "Elevating the leg might lead to a flexion contracture." · "I am sorry. We ran out of pillows. I can elevate it on a few blankets." · "Elevating the extremity may increase your chances of compartment syndrome." · "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that."
Apply a tourniquet.
A client had an above-the-knee amputation of the left leg related to complications from peripheral vascular disease. The nurse enters the client's room and observes the dressing and bed covers saturated with blood. What is the first action by the nurse? · Use skin clips to close the wound. · Apply a tourniquet. · Notify the health care provider. · Reinforce the dressing.
"A splint is applied when more swelling is expected at the site of injury."
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?
· Instruct on the use of an incentive spirometer. · Demonstrate the use of a pillow to splint the area. · Provide analgesics as prescribed. Remind to take deep breaths and cough every hour.
A client is diagnosed with several fractured ribs after a motor vehicle crash. Which actions will the nurse take when caring for this client? Select all that apply. · Instruct on the use of an incentive spirometer. · Demonstrate the use of a pillow to splint the area. · Provide analgesics as prescribed. · Apply a chest binder as prescribed. · Remind to take deep breaths and cough every hour.
traction
A client is experiencing pain, joint instability, and difficulty walking due to an injury to the knee ligaments. The injury was judged not to require surgery. Which intervention would not be included in this client's care? · joint immobilization · traction · limited weight bearing · ice and NSAIDs
Administer oxygen.
A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? · Elevate the affected extremity. · Administer oxygen. · Contact the health care provider. · Contact the nursing supervisor.
After 24 hours, apply heat for periods of 15 to 30 minutes.
A client presents at an ambulatory clinic and reports pain and aching in the lower left leg. After examining the client, a health care provider determines the client has experienced a strain related to the client's exercise regimen. The treatment plan includes analgesics, rest, and cold and heat therapies. Which guideline should be included in the care plan? · After 24 hours, apply heat for periods of 15 to 30 minutes. · Alternate heat and cold applications to the extremity continuously. · Apply cold packs to extremity continuously for the first 48 hours. · Begin physical training for 30 minutes, gradually increasing to 45 minutes over the next several days.
Sprain
A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? · Sprain · Strain · Contusion · Fracture
· splinting the injured limb · immobilizing the affected site covering the area with a sterile dressing if the fracture is open
A client sustains an open fracture of the left arm after an accident. What does emergency management of this fracture involve? Select all that apply. · splinting the injured limb · immobilizing the affected site · asking the client if they are able to move the arm · wrapping the arm in an ace bandage · covering the area with a sterile dressing if the fracture is open
Coughing and deep breathing with pillow splinting
A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client? · Mechanical ventilation · Chest strapping · Thoracentesis · Coughing and deep breathing with pillow splinting
Complex regional pain syndrome
A client who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold, and feeling clammy skin that is shiny and growing more hair in the injured extremity. The nurse should anticipate providing care for what complication? · Heterotrophic ossification · Reaction to an internal fixation device · Avascular necrosis of bone · Complex regional pain syndrome
joint manipulation and immobilization
A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform? · ice and immobilization · analgesia and immobilization · heat and immobilization · joint manipulation and immobilization
Client can demonstrate safe use of assistive devices.
A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? · Client is free of pain. · Client can demonstrate safe use of assistive devices. · Client has a healed, nontender, nonadherent scar. · Client can perform activities of daily living (ADLs) independently.
sprain
A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced? · contusion · sprain · All options are correct. · strain
Explain that the sensation being felt is normal and will not burn the client.
A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? · Explain that the sensation being felt is normal and will not burn the client. · Administer antianxiety and pain medication. · Remove the cast immediately, notifying the physician. · Call for assistance to hold the client in the required position until the cast has dried.
Cut a cast window.
A client with a fractured distal left radius reports discomfort at the cast site, with pain specifically in the upper forearm. What would the nurse expect the physician to do? · Apply a fiberglass cast. · Remove the cast. · Cut a cast window. · Initiate physical therapy.
· "I have a pins-and-needles sensation in my toes." · Dorsoplantar weak and unequal bilaterally · T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90% · "I cannot seem to catch my breath."
A client with a fractured femur is admitted to the nursing unit. Which assessment finding requires follow up by the nurse? Select all that apply. · "I have a pins-and-needles sensation in my toes." · Both feet warm with capillary refill < 3 seconds · Dorsoplantar weak and unequal bilaterally · T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90% · "I cannot seem to catch my breath."
Apply a trapeze to the bed frame.
A client with a fractured femur is placed in skeletal traction. Which intervention will increase client independence when moving in bed? · Instruct to use the elbows to reposition. · Remove the weights prior to repositioning. · Apply a trapeze to the bed frame. · Remind to use the heel of the unaffected foot to reposition.
· Elevate the extremity to heart level · Cover sharp fixator pins with caps · Monitor neurovascular status every 2 to 4 hours
A client with a fractured fibula has an external fixator device applied. Which interventions to care for this device will the nurse add to the client's plan of care? Select all that apply. · Elevate the extremity to heart level · Cover sharp fixator pins with caps · Tighten loose pins on the device during pin care · Monitor neurovascular status every 2 to 4 hours · Examine pin insertion sites daily
Document the findings.
A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? · Assess the client's hemoglobin and hematocrit. · Prepare for surgical removal of the fixator. · Notify the physician. · Document the findings.
Provide feedback on the client's strengths and available resources.
A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate? · Provide feedback on the client's strengths and available resources. · Encourage the client to perform range-of-motion (ROM) exercises to the right leg. · Request a referral to occupational therapy. · Provide wound care without discussing the amputation.
Teach the client how to prevent problems caused by immobility.
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? · Assess the client's level of consciousness. · Remove the traction at least every 8 hours. · Teach the client how to prevent problems caused by immobility. · Apply the traction straps snugly.
· Better molding to the client
A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast? · More breathable · Quicker drying · Longer-lasting · Better molding to the client
Turning from side to side
A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action? · Bearing down while having a bowel movement · Shifting one's weight in bed · Coughing without splinting · Turning from side to side
· Allowing the client to express grief · Introducing the client to local amputee support groups · Encouraging the client to care for the residual limb
A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) · Encouraging family and friends to refrain from visiting temporarily because this may increase the client's embarrassment · Encouraging the client to have family and friends view the residual limb to decrease self-consciousness · Allowing the client to express grief · Introducing the client to local amputee support groups · Encouraging the client to care for the residual limb
Assist with a gradual introduction of activity.
A nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury? · Apply a cold pack to the affected area every night. · Administer nonsteroidal anti-inflammatory drugs (NSAIDs) regularly. · Apply heat to the affected area every night. · Assist with a gradual introduction of activity.
Joint fracture
A nurse would most likely expect the need for open reduction for a client with which of the following? · Little bone separation · Soft tissue free of bone ends · Joint fracture · Closed fracture
As soon as tolerated, after a reasonable period of immobilization
A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin? · In 2 to 3 weeks, when callus ossification prevents easy movements of bony fragments · As soon as tolerated, after a reasonable period of immobilization · In about 4 to 5 weeks, after new bone is well established · In 2 to 3 months, after normal activities are resumed
The client's attitude
A rehabilitation nurse is working with a client who has had a below-the-knee amputation. In order to determine the client's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? · The client's presurgical level of function · The client's attitude · The client's learning style · The client's nutritional status
osteomyelitis
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? · osteomyelitis · hematoma · infection · hemorrhage
Fat embolism
After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? · Fat embolism · Volkmann's ischemic contracture · Compartment syndrome · Infection
Maintaining traction continuously to ensure its effectiveness
After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority? · Restricting the client's fluid and fiber intake to reduce the movement required for bedpan use · Maintaining traction continuously to ensure its effectiveness · Monitoring the client for skin breakdown · Supporting the traction weights with a chair or table to prevent accidental slippage
With the leg on the affected side abducted
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? · With the affected hip flexed acutely · With the leg on the affected side abducted · With the leg on the affected side adducted · With the affected hip rotated externally
Signs of neurovascular compromise
An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? · The presence of leg shortening · Signs of neurovascular compromise · The client's complaints of pain · The presence of internal or external rotation
The importance of adhering to the prescribed treatment and rehabilitation regimen
An elite high school football player has been diagnosed and treated for a shoulder dislocation. What should the nurse emphasize during health education to facilitate the player's rejoining the team? · The need to take analgesia regardless of the short-term absence of pain · The importance of monitoring for intracapsular bleeding once he resumes playing · The importance of adhering to the prescribed treatment and rehabilitation regimen · The fact that he has a permanently increased risk of future shoulder dislocations
Administer prescribed analgesics around-the-clock.
An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? Administer prescribed pain medication only when the client requests it. Administer prescribed analgesics around-the-clock. Avoid administering too much medication because the client is older. Give pain medication to the client after providing care.
Splint
The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis? Brace Skin traction Splint Cast
Crackles in the lung bases
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? · Client complains of pain in the affected rib area when taking a deep breath · Crackles in the lung bases · Heart rate of 94 beats/minute · Blood pressure of 140/90 mm Hg
Protect the affected leg from internal rotation.
The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? Keep the hip flexed by placing pillows under the client's knee. Protect the affected leg from internal rotation. Keep the affected leg in a position of adduction. Have the client reposition himself independently.
Keep the cast clean and dry.
The nurse is caring for a client with a spica cast. What is the nurse's priority intervention? · Promote elimination with a regular bedpan. · Position the client on the affected side. · Keep the legs in abduction. · Keep the cast clean and dry.
Weights hanging and touching the floor
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? · Body aligned opposite to line of traction pull · Pulleys without evidence of the obstruction · Ropes freely moving over pulleys · Weights hanging and touching the floor
Weights hanging and touching the floor
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? · Body aligned opposite to line of traction pull · Pulleys without evidence of the obstruction · Weights hanging and touching the floor · Ropes freely moving over pulleys
· "Metal pins will go through my skin to the bone."
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? · "A belt will go around my pelvis and weights will be attached." · "Metal pins will go through my skin to the bone." · "The traction can be removed once a day so I can shower." · "I will wear a boot with weights attached."
Foot drop
The nurse is very concerned about the potential debilitating complication of peroneal nerve injury. What symptom does the nurse recognize as a result of that complication? · Permanent paresthesias · Infection · Deep vein thrombosis (DVT) · Foot drop
· Excruciating pain · Decreased sensory function · Loss of motion
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) · Capillary refill less than 3 seconds · 2+ peripheral pulses in the affected distal pulse · Excruciating pain · Decreased sensory function · Loss of motion
Compartment syndrome.
Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? Compartment syndrome. Chronic venous insufficiency. Infection. Phlebitis
Assisting in early ambulation.
Which action would be most important postoperatively for a client who has had a knee or hip replacement? · Encouraging expressions of anxiety. · Providing crutches to the client. · Assisting in early ambulation. · Using a continuous passive motion (CPM) machine.
Encourage participation in ADLs
Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? · Promote intake of omega-3 fatty acids · Use frequent dependent positioning to prevent edema · Encourage participation in ADLs · Administer prescribed enema to prevent constipation
Nonunion
Which term refers to the failure of fragments of a fractured bone to heal together? · Nonunion · Malunion · Subluxation · Dislocation
The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices.
A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the nurse differentiate the first-degree strain from other strains and sprains? · The client has some edema of the left ankle with muscle spasms but is able to walk without assistive devices. · The client has ecchymosis, edema, and has no function of the left foot and ankle. · The client is unable to bear weight on the left ankle and has a large ecchymotic area. · The client complains of pain when the joint is moved and has mild edema.
Avascular necrosis may develop at the site if it is not promptly resolved.
An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement? The longer the joint is displaced, the more difficult it is to get it back in place. Avascular necrosis may develop at the site if it is not promptly resolved. The client's pain will increase until the joint is realigned. Dislocation can become permanent if the process of bone remodeling begins.
24 hours
An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker? · 24 hours · 1 week · 72 hours · 2 to 3 weeks
Notify the physician.
An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? · Document the findings. · Assess for pedal pulse and mobility of toes. · Remove the cast immediately. · Notify the physician.
· arthroscopic surgery · activity modification and joint rest · corticosteroid injections · nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse is caring for a client who has been diagnosed with a rotator cuff tear. What option(s) for treating this condition does the nurse identify? Select all that apply. · arthroscopic surgery · activity modification and joint rest · corticosteroid injections · nonsteroidal anti-inflammatory drugs (NSAIDs) · traction
Hypovolemic
The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury? · Neurogenic · Septic · Hypovolemic · Cardiogenic
· "Limit hip flexion to 90 degrees."
When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? · "Limit hip flexion to 90 degrees." · "Avoid weight bearing until the hip is completely healed." · "Perform rotation exercises each day." · "Intermittently cross and uncross your legs several times each day."
Pain
Which is a hallmark sign of compartment syndrome? · Edema · Motor weakness · Weeping skin surfaces · Pain
Prevent internal rotation of the affected leg.
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? · Keep the hip flexed by placing pillows under the client's knee. · Prevent internal rotation of the affected leg. · Use measures other than turning to prevent pressure ulcers. · Keep the affected leg in a position of adduction.
The skin may be covered with a yellowish crust that will shed in a few days.
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed? · The skin may be covered with a yellowish crust that will shed in a few days. · The leg strength is enforced by the wearing of the cast. · The leg will look as it did prior to the cast being applied. · The leg will look moist and will have small bumps that will go away in a few days.
Frequently assessing pain level · Ensuring that the weights are hanging freely · Assessing the client's alignment in the bed · Placing a trapeze on the bed
Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. · Frequently assessing pain level · Ensuring that the weights are hanging freely · Assessing the client's alignment in the bed · Removing skeletal traction to turn and reposition the client · Placing a trapeze on the bed
· Splint
Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides? · Trapeze · Continuous passive motion (CPM) device · Brace · Splint
· Cover the cast with plastic to insulate it
Which would be contraindicated as a component of self-care activities for the client with a cast? · Cushioning rough edges of the cast with tape · Elevate the casted extremity to heart level frequently · Do not attempt to scratch the skin under a cast · Cover the cast with plastic to insulate it
· arthroscopic surgery · NSAIDs · activity modification and joint rest
A client has been diagnosed with a rotator cuff tear. What are the options for treating this condition? Select all that apply. · traction · arthroscopic surgery · NSAIDs · activity modification and joint rest
Electrical stimulation
A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth? · Administration of low-dose heparin · Electrical stimulation · Joint fusion · Administration of antibiotics
Encouraging frequent use of the overbed trapeze
A client is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the client's need for exercise? · Performing massage to stimulate circulation · Encouraging the client to log roll side to side once per hour · Encouraging frequent use of the overbed trapeze · Performing gentle leg lifts with both legs
The bones of the left leg will be aligned. · Immobilization of the left leg will be maintained. · Muscle spasms will be relieved.
A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply. · Surgery will not be required. · Less pain medication will be required. · The bones of the left leg will be aligned. · Immobilization of the left leg will be maintained. · Muscle spasms will be relieved.
· Realignment of the fracture · Reduction of deformity · Minimization of muscle spasms
A client is placed in traction for a femur facture. The nurse would document which expected outcomes of traction? Select all that apply. · Realignment of the fracture · Reduction of deformity · Increased ability to bear weight · Minimization of muscle spasms · Full range of motion to extremity · Decreased pedal pulse
Assess vital signs and level of consciousness.
A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? · Administer pain medication per orders. · Assess vital signs and level of consciousness. · Assess pedal pulses. · Assess the diameter of the thigh every 15 minutes.
Assess vital signs and level of consciousness.
A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority? · Assess pedal pulses. · Assess the diameter of the thigh every 15 minutes. · Administer pain medication per orders. · Assess vital signs and level of consciousness.
· Maintaining antiembolic stockings · Increasing fiber intake · Administering enoxaparin
A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply. · Maintaining antiembolic stockings · Increasing fiber intake · Encouraging coughing exercises · Increasing fluid intake · Administering enoxaparin
"Describe the pain and rate it on the pain scale."
A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse? · "Describe the pain and rate it on the pain scale." · "Pain medication usually does not help this type of pain." · "Your left toes have been amputated." · "The pain is really from the nerves in the upper leg."
Osteomyelitis
A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication? · Septic arthritis · Cellulitis · Osteomyelitis · Sepsis
Keep ahead of the pain by administering analgesia as scheduled and PRN. Increase fluid intake. Perform prescribed ankle and foot exercises as ordered.
A nurse is caring for a client with a hip fracture after a fall from a ladder. Which actions will the nurse provide to prevent complications associated with this injury? Select all that apply. Keep ahead of the pain by administering analgesia as scheduled and PRN. Increase fluid intake. Remain on bed rest for 14 days or until instructed by the orthopedic surgeon. Administer supplementary oxygen when transferring or mobilizing. Perform prescribed ankle and foot exercises as ordered.
Call the physician to inform them of the findings.
The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse? · Call the physician to inform them of the findings. · Increase the intravenous fluids for hemorrhage. · Request an antihistamine for the allergic reaction. · Administer pain medication.
· Loss of motion · Excruciating pain Decreased sensory function
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) · Decreased sensory function · 2+ peripheral pulses in the affected distal pulse · Capillary refill less than 3 seconds · Loss of motion · Excruciating pain
· The client with hemorrhage in the site of injury · The client with a plaster cast applied immediately after injury · The client with elevated pressure within the muscles
Which client(s) is most likely to have compartment syndrome after sustaining a fracture? Select all that apply. · The client with hemorrhage in the site of injury · The client with a plaster cast applied immediately after injury · The client using ice to control pain in the extremity · The client who sustained a clavicle fracture · The client with elevated pressure within the muscles
Hemorrhage
Which factor may contribute to compartment syndrome? · Macular lesion · Venous thromboembolus · Disuse syndrome · Hemorrhage
· "Place pillows between your legs when you lay on your side." · "Use a raised toilet seat and high-seated chair." · "Avoid bending forward when sitting in a chair."
Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.) · "Place pillows between your legs when you lay on your side." · "Use a raised toilet seat and high-seated chair." · "It is okay to briefly flex the hip to put on your clothes." · "You may cross your legs at the ankles only." · "Avoid bending forward when sitting in a chair."
Decrease space between opposing structures
Which is an inappropriate use of traction? · Minimize muscle spasms · Immobilize a fracture · Reduce deformity · Decrease space between opposing structures
· Cushion rough edges of the cast with tape
Which would be consistent as a component of self-care activities for the client with a cast? · Cushion rough edges of the cast with tape · Use a plastic hanger wrapped in gauze to scratch under the cast. · Frequently place the casted extremity in a dependent position · Cover the cast with plastic to insulate it
· Assess the pin insertion site every 8 hours.
A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care? · Apply occlusive dressings to the pin sites. · Encourage the client to push up with the elbows when repositioning. · Encourage the client to perform isometric exercises once a shift. · Assess the pin insertion site every 8 hours.
Abduction
A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation? · Adduction · Abduction · Internal rotation Flexion
fusion of a joint (most often the wrist or knee) for stabilization and pain relief.
Arthrodesis is: · fusion of a joint (most often the wrist or knee) for stabilization and pain relief. · total reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. · replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. · cutting and removal of a wedge of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.
Compartment syndrome
In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? · Disseminated intravascular coagulation · Compartment syndrome · Fat embolism syndrome · Carpal tunnel syndrome
Crepitus
The nurse is assessing a client's knee. The area has a grating sensation. What would this be documented as? · Shortening · Dislocation · False motion · Crepitus
Risk for ineffective therapeutic regimen management
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: · Situational low self-esteem · Risk for avascular necrosis of the joint · Risk for ineffective therapeutic regimen management · Disturbed body image
Fat emboli syndrome
The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient? · Fat emboli syndrome · Disseminated intravascular coagulation · Polyethylene-induced infection · Pneumonia
greenstick.
The type of fracture described as having one side of the bone broken and the other side bent would be: · oblique. · greenstick. · transverse. spiral
The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins.
Which statement describes external fixation? · The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. · The bone is surgically exposed and realigned. · The bone is restored to its normal position by external manipulation. · The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins.
Hip spica
Which type of cast encloses the trunk and a lower extremity? · Short-leg · Long-leg · Body cast · Hip spica
· "Keep your right leg elevated above heart level."
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? · "Use a knitting needle to scratch itches inside the cast." · "A foul smell from the cast is normal." · "Cover the cast with a blanket until the cast dries." · "Keep your right leg elevated above heart level."
Compound
A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? · Greenstick · Oblique · Spiral · Compound
Short leg cast
A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied? · Long leg cast · Short leg cast · Walking cast · Hip spica cast
stretched or pulled beyond its capacity
A client has been diagnosed with a muscle strain. What does the physician mean by the term "strain"? · injury resulting from a blow or blunt trauma · subluxation of a joint · stretched or pulled beyond its capacity · injuries to ligaments surrounding a joint
stretched or pulled beyond its capacity
A client has been diagnosed with a muscle strain. What does the physician mean by the term "strain"? · subluxation of a joint · injury resulting from a blow or blunt trauma · injuries to ligaments surrounding a joint · stretched or pulled beyond its capacity
Hematoma
A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period? · Chronic osteomyelitis · Hematoma · Neuroma · Unexplainable burning pain (causalgia)
"We will need to monitor the status of the laceration to be sure it does not get infected."
A client is seen in the emergency department for an injury acquired from falling off of a bicycle and fracturing the arm. The client also has a long laceration that has been sutured in the same area. The client asks the nurse why a splint is applied and not a cast. What is the best explanation by the nurse? · "We will need to monitor the status of the laceration to be sure it does not get infected." · "The splint is less expensive than the cast." · "The arm does not require the same immobilization that a leg fracture would." · "You will be able to wear the splint longer than you would a cast."
· "Apply ice packs for the first 24 to 48 hours, then apply heat packs."
A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? · "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." · "Apply ice packs for the first 24 to 48 hours, then apply heat packs." · "Apply ice packs for the first 12 to 18 hours." · "Apply heat packs for the first 24 to 48 hours."
Sprain
A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury? · Sprain · Dislocation · Strain · Subluxation
"I don't know if I'll be able to get off that low toilet seat at home by myself."
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? · "The occupational therapist is showing me how to use a sock puller to help me get dressed." · "I don't know if I'll be able to get off that low toilet seat at home by myself." · "I'll need to keep several pillows between my legs at night." "I need to remember not to cross my legs. It's such a habit
Keeping a pillow between the client's legs at all times
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? · Turning the client from side to side every 2 hours · Performing passive range-of-motion (ROM) exercises on the client's legs once each shift · Maintaining the client in semi-Fowler's position Keeping a pillow between the client's legs at all times
Balanced traction allows for greater client movement and independence than other forms of traction.
The orthopedic surgeon has prescribed balanced skeletal traction for a client. What advantage is conferred by balanced traction? · Balanced traction can be applied at night and removed during the day. · Balanced traction facilitates bone remodeling in as little as 6 days. · Balanced traction is portable and may accompany the client's movements. · Balanced traction allows for greater client movement and independence than other forms of traction.
avascular necrosis
There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? · fat embolism · avascular necrosis · pulmonary embolism · shock
Increase fiber intake.
To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan? · Increase fiber intake. · Reduce fluid intake. · Increase calorie intake. · Remove the weights during linen changes.
· History of diabetes
Which factor inhibits fracture healing? · Age of 35 years · Immobilization of the fracture · Increased vitamin D and calcium in the diet · History of diabetes
The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.
Which is not a guideline for avoiding hip dislocation after replacement surgery. · Keep the knees apart at all times. · Never cross the legs when seated. · Put a pillow between the legs when sleeping. · The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.
Acute respiratory distress syndrome
Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome? · Stroke · Pulmonary embolism · Myocardial infarction · Acute respiratory distress syndrome
Volkmann's contracture
Which may occur if a client experiences compartment syndrome in an upper extremity? · Volkmann's contracture · Subluxation · Callus · Whiplash injury
"The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device."
Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? · "The client is receiving physical therapy twice per day, so the client doesn't need a continuous passive motion device." · "The continuous passive motion device can decrease the development of adhesions." · "Bleeding is a complication associated with the continuous passive motion device." · "Monitoring skin integrity is important while the continuous passive motion device is in place."
Left hip arthroscopy
A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for? · Open reduction and internal fixation of the left hip. · Left hip arthroscopy · Left hip arthroplasty · Closed reduction of the left hip.
Total arthroplasty
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for? · Osteotomy · Total arthroplasty · Arthrodesis · Hemiarthroplasty
"I was worried I would have an incision and scar."
The nurse is admitting a client who is to undergo an open reduction with internal fixation for a fractured femur. About which comment by the client should the nurse be most concerned? · "The surgeon is planning to use a metal plate and screws to fix my hip." · "The surgeon can see the bones when putting them in correct position." · "I was worried I would have an incision and scar." · "A joint replacement or bone graft is not necessary."
Drainage from wound suction device = 100 ml
The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse? · Drainage from wound suction device = 100 ml · Crackles that clear with coughing · Previous shift urine output = 500 ml · Hypoactive bowel sounds
A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter
Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first? · A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter · A 60-year-old female, who is in traction to manage chronic muscle spasms, who is requesting assistance to order her evening meal · A 56-year-old male, who had an arthroscopy of his left knee 3 hours ago, who is asking to be discharged · The order doesn't matter; all clients are of equal priority
650 ml bloody drainage in drain wound Knee flexion at 30 degrees
Which evaluation finding requires follow up by the nurse caring for a client with a total knee replacement? Select all that apply. · Client ambulates 10 feet by postoperative day 2 · 650 ml bloody drainage in drain wound · Client reports pain rating of 2. · Pedal pulses strong and equal bilaterally Knee flexion at 30 degrees
· Supervise the client during transfers. · Inspect pin sites for signs of infection. · Perform pin care as ordered. · Perform neurovascular assessment.
Which intervention should the nurse implement with the client who has an external fixator? Select all that apply. · Supervise the client during transfers. · Inspect pin sites for signs of infection. · Perform pin care as ordered. · Perform neurovascular assessment. · Turn the clamps by one-half every day.
Impaired physical mobility related to trauma
Which nursing diagnosis takes highest priority for a client with a compound fracture? · Activity intolerance related to weight-bearing limitations · Infection related to effects of trauma · Impaired physical mobility related to trauma · Imbalanced nutrition: Less than body requirements related to immobility
Encourage participation in ADLs
Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? · Use frequent dependent positioning to prevent edema · Encourage participation in ADLs · Promote intake of omega-3 fatty acids · Administer prescribed enema to prevent constipation
Disseminated intravascular coagulation (DIC)
Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? · Fat embolism syndrome (FES) · Avascular necrosis (AVN) · Complex regional pain syndrome (CRPS) · Disseminated intravascular coagulation (DIC)
Bending down to put on socks
A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? · Straining during a bowel movement · Lifting items above shoulder level · Bending down to put on socks · Transferring from a sitting to standing position
Preventing additional injury · Providing support · Controlling movement
A client has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. · Immobilizing prior to surgery · Preventing additional injury · Providing support · Controlling movement · Promoting bone remodeling
· Peripheral pulses +2 bilaterally · Capillary refill less than 3 seconds · Elbows are free of skin breakdown · Repositions self with trapeze
A nurse is caring for a client in skeletal leg traction. Which nursing assessment findings indicate the client has met expected outcomes? Select all that apply. · Peripheral pulses +2 bilaterally · Capillary refill less than 3 seconds · Elbows are free of skin breakdown · Repositions self with trapeze · Right calf warm and swollen
· Gradually resume activities and exercise. · Apply an emollient lotion to soften the skin. · Control swelling with elastic bandages, as directed.
A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.) · Gradually resume activities and exercise. · Use a razor to shave the dead skin off. · Apply an emollient lotion to soften the skin. · Control swelling with elastic bandages, as directed. · Use friction to remove dead surface skin by rubbing the area with a towel.
Peroneal nerve
A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur? · Popliteal artery · Peroneal nerve · Posterior tibialis · Dorsalis pedis
Fat emboli
A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? · Pneumonia · Cardiac tamponade · Spontaneous pneumothorax · Fat emboli
· Instruct the client on isometric exercises for immobilized extremity. · Ensure the pins or wires are covered with caps. · Position trapeze within the client's reach.
Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. · Instruct the client on isometric exercises for immobilized extremity. · Ensure the pins or wires are covered with caps. · Apply 8-pound weight to the rope. · Remove foam boot and inspect skin daily. · Position trapeze within the client's reach.
Apply antiembolism stockings
Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? · Apply cold packs · Apply antiembolism stockings · Instruct about using client-controlled analgesia, if prescribed · Instruct about exercise, as prescribed
Apply a tourniquet.
A client has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? · Apply sterile gauze. · Apply a tourniquet. · Elevate the residual limb. · Call the surgeon.
"I'll make sure to keep my ankle elevated as much as possible."
A client is being discharged from the Emergency Department after being diagnosed with a sprained ankle. Which client statement indicates the client understands the discharge teaching? · "I'll start with ice for the first couple of hours and then apply heat." · "I'll get the prescription filled for the narcotic pain reliever." · "I'll make sure to keep my ankle elevated as much as possible." · "I need to stay off my ankle for at least the next 3 to 4 weeks."
Incomplete
A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture? · Incomplete · Stress · Compression · Closed
