Exam 1: Fracture Questions

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? 1. left hand 2. right hand 3. stronger hand 4. dominant hand

1 rationale: A cane should be used on the unaffected side. Weight-bearing can be shared by a cane and an affected leg when they are advanced forward together. Teaching the client to use the right hand promotes leaning toward the affected side and does not permit sharing of weight by the stronger left side of the body. Teaching the client to use the stronger hand is unsafe; the stronger hand may not be the left hand. Teaching the client to use the dominant hand is unsafe; the dominant hand may not be the left hand.

A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. What does the nurse suspect as the cause of the fracture? 1. Child abuse 2. Vitamin D deficiency 3. Osteogenesis imperfecta 4. Inadequate calcium intake

1 rationale: Injuries in various stages of healing are the classic sign of child abuse. Vitamin D deficiency, osteogenesis imperfecta, and inadequate calcium intake may all be investigated after child abuse has been ruled out.

To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction? 1. Elevate the head of the bed. 2. Add more weight to the traction. 3. Raise the foot of the bed slightly. 4. Tie a chest restraint around the client.

3 rationale: Elevating the foot of the bed uses gravity and the client's weight for countertraction. Elevating the head of the bed will not increase countertraction. Adding more weight to the traction will increase traction rather than countertraction. Tying a chest restraint around the client will have no effect on countertraction.

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? 1. relieving muscle spasm and pain 2. preventing contractures from developing 3. keeping the client from turning and moving in bed 4. maintaining the limb in a position of external rotation

1 rationale: Traction may be used in the treatment of a fractured hip to align the bones (reduction of fracture). If such traction is not employed, the muscles may go into spasm, shifting the bone fragments and causing pain. Traction is a temporary measure before surgery; contractures result from a shortening of the muscles by prolonged immobility. Although the affected extremity must be properly aligned, turning and moving the client can and should be done. External rotation is contraindicated and prevented by the use of positioning aids.

A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply. 1. assisting the splitting the cast 2. assessing urine output 3. evaluating the pain on a scale 4. applying splints to the injured part 5. placing cold compresses to the affected area

1, 2, 3 rationale: Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse should assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse should evaluate the pain on a scale from 0 to 10; this helps to plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.

A client is ready to walk with crutches after knee surgery. Which crutch-walking technique will the nurse most likely need to reinforce after the client returns from physical therapy? 1. two point 2. four point 3. three point 4. swing through

3 rationale: The three-point gait, which requires arm strength, is used when a limb cannot bear weight. The affected leg and crutches are advanced together, and the strong leg swings through. Two-point and four-point gaits require weight bearing on both feet. Swing-through does not simulate ambulation and is not appropriate for this client.

A nurse notes the weights attached to a 7-year-old child in traction are touching the floor. What action should the nurse take? 1. Raising the foot of the bed 2. Lengthening the traction rope 3. Notifying the healthcare provider 4. Moving the child toward the head of the bed

4 rationale: Moving the child toward the head of the bed will produce sufficient countertraction to raise the weights off the floor. Raising the foot of the bed may provide excessive countertraction. Lengthening the traction rope is contraindicated because it will not raise the weights off the floor. Readjusting the traction is the nurse's responsibility; there is no need to notify the healthcare provider.

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? 1. nausea 2. dyspnea 3. orthopnea 4. paresthesia

2 rationale: FES is clinically manifested by dyspnea because of low levels of arterial oxygen. Nausea and orthopnea are not seen in FES. However, tachypnea, headache, and lethargy are seen in clients with FES. Paresthesia occurs with compartment syndrome.

A nurse is caring for a client with a fracture of the head of the femur. The primary healthcare provider places the client in Buck extension. What explanation does the nurse give the client for why the traction is being used? 1. Reduces muscle spasms 2. Prevents soft tissue edema 3. Reduces the need for cast application 4. Prevents damage to the surrounding nerves

1 Buck extension is used to reduce the fracture, align the bone, and temporarily reduce muscle spasms. Edema occurs because of tissue trauma and will not be prevented by Buck extension. A fractured head of the femur is repaired via internal fixation; a cast is unnecessary. Damage already has occurred at the time of trauma and is not prevented by Buck extension.

Which hormonal deficiency would increase the client's risk for fractures? 1. Growth hormone 2. Follicle-stimulating hormone 3. Thyroid-stimulating hormone 4. Adrenocorticotropic hormone

1 rationale: Growth hormone deficiency causes decrease in bone density, thereby increasing the risk of fractures. Follicle-stimulating hormone deficiency causes amenorrhea, decreased libido, and infertility in women and impotence in men. Thyroid-stimulating hormone deficiency causes menstrual abnormalities and hirsutism. Adrenocorticotropic hormone deficiency causes hypoglycemia and hyponatremia.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? 1. Picks up the walker and carries it for short distances 2. Uses the walker only when someone else is present 3. Moves the walker no more than 12 inches (30.5 cm) in front of the client during use 4. States that a walker will be purchased on the way home from the hospital

3 rationale: Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches (30.5 cm) in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? 1. Cardiogenic shock 2. Hypervolemic shock 3. Hemorrhagic shock 4. Septic shock

3 rationale: The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number. _______ Total GCS score

The score is 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of one point in each of the categories: eye opening response, best verbal response, and best motor response.

What are the diagnostic abnormalities present in a client with fat embolism syndrome? Select all that apply. 1. decreased PaO2 2. increased platelet count 3. increased fat cells in urine 4. decreased hematocrit level 5. decreased prothrombin time

1, 3, 4 rationale: The diagnostic abnormalities present in a client with fat embolism syndrome are decreased PaO 2, increased fat cells in urine, decreased hematocrit level, decreased platelet count, and prolonged prothrombin time.

X-ray films reveal that a client has closed fractures of the right femur and tibia. In addition, multiple soft-tissue contusions are present. Which action is most important for the nurse to take? 1. Perform a neurovascular assessment of the extremity. 2. Reassure the client that these injuries are not that serious. 3. Gather equipment needed for the application of skeletal traction. 4. Prepare the client for a surgical reduction of the injured extremity.

1 rationale: Identifying the status of the damage is the priority. Before a treatment protocol is determined, the presence of nerve or vascular damage and compartment syndrome must be identified. False reassurance is never appropriate. Skeletal traction is used rarely. Closed fractures in the absence of soft tissue damage generally are reduced by manipulation. Closed fractures with soft tissue damage may require an external fixation device to reduce the fracture, immobilize the bone, and allow for treatment of the soft tissue damage. Preparing the client for surgery is premature; more data are necessary before a treatment option is determined.

After a lateral crushing chest injury, obvious right-sided paradoxical motion of a client's chest demonstrates multiple rib fractures, resulting in a flail chest. Which complication associated with this injury should the nurse assess in this client? 1. mediastinal shift 2. tracheal laceration 3. open pneumothorax 4. pericardial tamponade

1 rationale: Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return. Tracheal laceration is unlikely with a crushing injury to the chest. Flail chest is a closed chest injury; open pneumothorax results from a penetrating injury to the chest wall. Pericardial tamponade is associated with a cardiac contusion and usually occurs from a sternal, not lateral, compression injury.

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking? 1. lifting weights 2. changing bed positions 3. caring for the residual limb 4. performing phantom limb exercises

1 rationale: Preparation for crutch walking includes exercises to strengthen arm and shoulder muscles. Position changes help prevent hip flexion contractures but do not prepare the client for crutch walking. Caring for the residual limb promotes healing and helps prepare the limb for the prosthesis; it does not prepare the client for crutch walking. The phantom limb sensation includes a feeling that the absent limb is present; there are no specific exercises for this phenomenon.

An orthopedic surgeon plans to have a school-aged child with cerebral palsy walk with crutches. What should the nurse determine before preparing this child for crutch-walking? 1. Weight-bearing ability of the child's four extremities 2. The power in the child's trunk to drag the legs forward when the child is erect 3. Whether the child's circulation can tolerate the body's being placed in an erect position 4. The ability of the child's shoulder girdle to support the body's weight when it leaves the floor

1 rationale: The choice of gait is based on the weight-bearing capabilities of each of the four extremities. Assessment of the extremities takes priority over assessment of the trunk. The child with cerebral palsy uses upper-extremity strength for crutch control and lower-extremity strength to facilitate some movement. The child with cerebral palsy is unlikely to have orthostatic circulatory impairment. Because of decreased muscle control, it is unlikely that the child is able to use a gait involving complete support of body weight off the floor.

While a nurse is providing food to a client in traction, the client reports feeling uncomfortable from being in the same position. Which nursing intervention is priority in this situation? 1. Repositioning the client 2. Offering basic hygiene measures 3. Assisting the client with the meal 4. Providing health teaching to the client

1 rationale: The nurse should first reposition the client so that he or she is in a more comfortable position, and then the nurse should offer basic hygienic measures. The nurse should assist the client with the meal after repositioning. Health education should be provided after repositioning.

A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's best initial response? 1. "I can't, because the weights are needed to keep the bone aligned." 2. "I will remove half of the weights and notify your primary healthcare provider." 3. "I'll get your prescribed pain medication to help relieve your discomfort." 4. "I have to follow the primary healthcare provider's directions, and releasing weights is not prescribed."

1 rationale: The response "I can't, because the weights are needed to keep the bone aligned" explains why the traction may not be released; a continuous pull must be maintained. Reducing the weight requires a primary healthcare provider's prescription; removing half the weights will not maintain the bone in alignment. The response "I'll get your prescribed pain medication to help relieve your discomfort" ignores the client's request to release the traction; further assessment is needed. Although the response "I have to follow the primary healthcare provider's directions, and releasing weights is not prescribed" is a true statement, it does not provide the rationale as to why the weights should not be released.

A client sustains a fracture of the femur after jumping from the second story of a building during a fire. The client is placed in Buck traction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. What should the nurse do to alleviate this problem? 1. Elevate the foot of the bed. 2. Shorten the rope on the weights. 3. Release the traction so the client can be repositioned. 4. Move the client toward the head of the bed every couple of hours.

1 rationale: The response "I can't, because the weights are needed to keep the bone aligned" explains why the traction may not be released; a continuous pull must be maintained. Reducing the weight requires a primary healthcare provider's prescription; removing half the weights will not maintain the bone in alignment. The response "I'll get your prescribed pain medication to help relieve your discomfort" ignores the client's request to release the traction; further assessment is needed. Although the response "I have to follow the primary healthcare provider's directions, and releasing weights is not prescribed" is a true statement, it does not provide the rationale as to why the weights should not be released.

What is the role of unlicensed assistive personnel (UAP) in caring for a client with a cast or in traction? Select all that apply. 1. Applying ice to the cast 2. Positioning the casted extremity above heart level 3. Marking the circumference of any drainage on the cast 4. Looking for clinical manifestations of compartment syndrome 5. Teaching range-of-motion exercises to the client and caregiver

1, 2 rationale: The role of unlicensed assistive personnel (UAP) in caring for the client with a cast or in traction involves applying ice to the cast and positioning the casted extremity above heart level. The licensed practical/vocational nurse (LPN/LVN) marks the circumference of any drainage on the cast. The registered nurse (RN) assesses the client for clinical manifestations of compartment syndrome and teaches the client and caregiver range-of-motion exercises.

The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? Select all that apply. 1. The crutches should reach 2 inches (5 centimeters) below the axillae. 2. The tips of the crutches should rest 6 inches (15.2 centimeters) outside the feet. 3. There should be a snug fit under the axillae when the child walks. 4. There should be a slight stoop of the shoulders when the child walks. 5. The elbows should be extended when the crutches are held at the crossbar.

1, 2 rationale: There is no pressure on the brachial plexus when the crutches reach to 2 inches (5 centimeters) below the axillae. Placing the ends of the crutches 6 inches (15.2 centimeters) from the outsides of the feet provides the maximal base of support when the child ambulates. A snug fit can cause pressure and therefore injury to the brachial plexus. Stooping of the shoulders when the child walks indicates that the crutches are too short. When the child is holding the crossbar, the elbows should be flexed slightly (no more than 30 degrees), and the shoulders should be straight.

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply. 1. Fat cells in the urine 2. PaO 2 value of 58 mm Hg (7.73 kPa) 3. Hematocrit value of 30% (0.30) 4. Platelet count of 160,000/µL (160 x 10 9/L) 5. Prothrombin time of 12 seconds

1, 2, 3 rationale: and hematocrit of 30% (0.30) are all indicative of fat embolism syndrome (FES). FES is characterized by the presence of systemic fat globules, which are distributed into tissues and organs after a traumatic skeletal injury. The presence of fat cells in the urine indicates FES. Fat emboli in the lungs cause a hemorrhagic interstitial pneumonitis that produces signs and symptoms of acute respiratory distress syndrome (ARDS) and decreased partial pressure of arterial oxygen. The normal partial pressure of arterial oxygen is 80 to 100 mm Hg (10.6-13.33 kPa). The normal hematocrit value is 40% to 50% (0.40-0.50). Poor oxygen exchange decreases the hematocrit value in a client with FES. The normal platelet count is in the range of 150,000 to 450,000 platelets per µL of blood (150-450 x 10 9/L). The platelet count is decreased in FES. A platelet count of 160,000/µL (160 x 10 9/L) is a normal finding. Normal prothrombin time is in the range of 12 to 13 seconds. Prothrombin time is prolonged in FES, but a prothrombin time of 12 seconds is normal.

What is the role of a Licensed Practical Nurse (LPN) while caring for the client with a cast or traction? Select all that apply. 1. Monitoring skin integrity around the cast 2. Marking circumference of any drainage on the cast 3. Teaching the client and caregiver range-of-motion (ROM) exercises 4. Performing neurovascular assessments on the affected extremity 5. Checking color, temperature, capillary refill, and pulses distal to the cast

1, 2, 5 rationale: The role of a Licensed Practical Nurse (LPN) while caring for the client with a cast or traction is monitoring skin integrity around the cast, marking circumference of any drainage on the cast, and checking color, temperature, capillary refill, and pulses distal to the cast. The role of the Registered Nurse (RN) while caring for the client with a cast or traction is teaching the client and caregiver range-of-motion (ROM) exercises and performing neurovascular assessments on the affected extremity.

A client suffered an injury to the leg as a result of a fall. X-ray films indicate an intertrochanteric fracture of the femur. The client will be placed in Buck traction until surgery is performed. When considering the client's plan of care, the nurse recalls that the primary purpose of Buck traction is to do what? 1. Reduce the fracture. 2. Immobilize the fracture. 3. Maintain abduction of the leg. 4. Eliminate rotation of the femur.

2 rationale: A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema. The fracture will be reduced by surgery; Buck traction is a temporary measure before surgery. Moving the leg away from the midline will not keep the leg in alignment; it is not the purpose of Buck traction. External rotation of the femur may still occur with Buck traction.

A 90-year-old resident of a nursing home falls and fractures the proximal end of the right femur. The surgeon plans to reduce the fracture with an internal fixation device. What general fact about the older adult should the nurse consider when caring for this client? 1. aging causes a lower pain threshold 2. physiologic coping defenses are reduced 3. most confused states result from dementia 4. older adults psychologically tolerate changes well

2 rationale: Aging causes a lowering of the physiologic coping reserve of various systems of the body. The pain threshold increases with aging. There are many etiologies for confusion (e.g., drug intolerance, altered metabolic state, unfamiliar surroundings). As individuals age they become more entrenched in ideas, environment, and objects that are familiar, and thus do not tolerate change well.

A nurse is presenting a community education program about osteoporosis at a women's health conference. What factor should the nurse explain has contributed to the increased incidence of fractures associated with osteoporosis in the United States? 1. dietary use of fat-free milk 2. aging of the American population 3. increased number of hysterectomies 4. immobility associated with early retirement

2 rationale: Because more people are living longer, the problem of osteoporosis in older adults, especially older women, is increasing. The dietary use of fat-free milk is unrelated to osteoporosis; the fat that is removed from milk does not contain calcium. The increase in the number of hysterectomies is unrelated to osteoporosis. Only the uterus is removed with a hysterectomy. Early retirement does not imply inactivity or immobility.

The nurse has provided teaching to a client with impaired balance, who uses a walker when ambulating. The nurse observes the client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client does what? 1. Slides toward the edge of the seat before standing 2. Holds both handles of the walker while rising to the standing position 3. Moves forward into the walker after transferring from sitting to standing 4. Stands in place holding on to the walker for at least 30 seconds before walking

2 rationale: Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position. Sliding toward the edge of the seat moves the center of gravity of the body toward the desired direction of movement, which facilitates the transfer. Holding both handles and moving forward into the walker provides the maximum support afforded by a walker. Standing in place after rising allows the body's vasomotor responses to adjust to the vertical position, minimizing orthostatic hypotension.

Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? 1. carelessness 2. fragility of bone 3. sedentary existence 4. rheumatoid diseases

2 rationale: Bones become more fragile because of loss of bone density associated with the aging process; this often is associated with lower circulating levels of estrogens or testosterone. Carelessness is a characteristic applicable to certain individuals rather than to people within a developmental level. Although prolonged lack of weight-bearing activity is associated with bone demineralization, hip fractures also occur in active older adults. Rheumatoid diseases can affect the skeletal system but do not increase the incidence of hip fractures.

The nurse is caring for a client with fat embolism syndrome (FES). Which anatomical part of the bone depicted in the figure is responsible for the client's condition? 1. A 2. B 3. C 4. D

2 rationale: Choice B depicts spongy cancellous tissue. Softer cancellous tissue contains large spaces or trabeculae, which are filled with red and yellow marrow. Yellow marrow contains fat cells that may be dislodged and enter the bloodstream, which can cause FES. Choice A indicates articular cartilage, which is a smooth white tissue that covers the ends of bones. Choice C indicates compact bone, which is hard due to inorganic calcium salt deposits. Choice D depicts bone cells (osteocytes) present in the deepest layer of the periosteum.

A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the primary healthcare provider. What must the nurse ensure when adjusting the crutches? 1. That they reach to 1 inch (2.5 centimeters) below the axillae 2. That they extend to 6 inches (15.2 centimeters) from the side of each foot 3. That the elbows are extended when the crutches are held by the crossbars 4. That the shoulders are slightly stooped when the crutches are bearing body weight

2 rationale: Having the crutches extend to 6 inches (15.2 centimeters) from the sides of the feet ensures the maximal base of support when the adolescent ambulates. Having the crutches reach to 1 inch (2.5 centimeters) below the axillae may cause trauma to the brachial plexus; the crutches should be 2 inches (5 centimeters) below the axillae. The elbows should be flexed, not extended, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short, which could result in trauma to the brachial plexus.

A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The primary healthcare provider prescribes ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's initial action? 1. Demonstrate the swing-through crutch walking gait. 2. Determine whether the client has ever used crutches before. 3. Introduce the client to another client who is using crutches. 4. Provide a pamphlet that has information about using crutches.

2 rationale: Information about the client's experiential background will influence the teaching plan. A teaching plan should be formulated based on what a client does or does not know. Demonstrating the swing-through crutch walking gait may be done later. Also, the swing-through gait may be used initially. Introducing the client to another client who is using crutches may or may not be done later. The focus should be on the client at this time. Providing a pamphlet that has information about using crutches should be done eventually but is not the priority at this time.

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what? 1. Double the intake of vitamin C. 2. Remove loose rugs from the environment. 3. Avoid taking showers until the cast is removed. 4. Increase weight bearing on the injured leg gradually.

2 rationale: Loose rugs can interfere with crutch walking and cause a fall; they should be removed to prevent further injury. Calcium rather than vitamin C is encouraged to enhance bone healing; vitamin C minimizes capillary fragility. It is not within the legal role of the nurse to encourage the client to increase the dose of any medication without a healthcare provider's prescription. The client may shower if the cast is protected from becoming wet. Decisions regarding weight bearing are a medical, not a nursing, responsibility.

Which nursing intervention is most appropriate for a client in skeletal traction? 1. Add and remove weights as the client desires. 2. Assess the pin sites at least every shift and as needed. 3. Ensure that the knots in the rope are tied to the pulley. 4. Perform range of motion to joints proximal and distal to the fracture at least once a day.

2 rationale: Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

To help a client prepare for walking with crutches, what should the nurse instruct the client to do? 1. Use the trapeze to strengthen the biceps muscles. 2. Exercise with or without weights to strengthen the muscles of the upper extremities. 3. Keep the affected limb in extension and abduction to prevent contractures. 4. Perform isometric exercises of the hamstring muscles while sitting in a chair until circulatory status is stable.

2 rationale: Preparing muscles that are used in crutch walking (e.g., triceps, finger flexors, wrist extensors, and elbow extensors) is imperative. The biceps are not the major muscles required for crutch walking. Contractures of the limb will not have a great influence on the ability to use crutches. Strengthening the hamstring muscles will not assist in the use of crutches.

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. What should the nurse do first? 1. obtain vital signs 2. administer oxygen 3. get the healthcare provider 4. place the client in the high-Fowler position

2 rationale: Vital signs should be done after oxygen administration. Obtaining vital signs will delay an intervention that may help reduce the client's distress. The client probably has a fat embolus; oxygen reduces the surface tension of fat globules, reducing hypoxia. Interventions should be initiated to help the client before taking the time to notify the healthcare provider. Placing the client in the high-Fowler position will cause hip flexion, putting stress on the fractured femur; the low or semi-Fowler positions are preferred.

A nurse is determining which tasks to delegate. Which actions should a registered nurse perform while caring for a client in traction? Select all that apply. 1. Padding traction connections 2. Determining correct body alignment 3. Assessing complications associated with immobility 4. Teaching the client about range-of-motion (ROM) exercises 5. Assisting the client with passive and active range-of-motion (ROM) exercises

2, 3, 4 rationale: The registered nurse (RN) has to assure that the client is in proper body alignment to maintain effectiveness of the traction. It is the responsibility of the RN to assess for complications associated with immobility such as wound infection, constipation, and deep vein thrombosis. The RN has to teach the client about range-of-motion (ROM) exercises to help foster faster recovery. The licensed practical nurse (LPN) should pad the traction connections to prevent skin irritation. Unlicensed assistive personnel (UAP) should assist the client with passive and active ROM exercises as directed by the RN.

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply. 1. splitting the cast in half 2. applying cold compresses 3. reducing the traction weight 4. loosening the client's bandage 5. elevating the extremity above heart level

2, 5 rationale: Cold compresses and elevating above the heart level are contraindicated for compartment syndrome. Compartment syndrome is a condition in which swelling and increased pressure within a limited space (a compartment) press on and compromise the function of blood vessels, nerves, and tendons that run through that compartment. Application of cold compresses could result in vasoconstriction and exacerbate compartment syndrome. Elevating the extremity above heart level could lower venous pressure and slow arterial perfusion. Splitting the cast in half decreases pressure and is beneficial in treating compartment syndrome. Reducing traction weight is beneficial because it decreases external circumferential pressure. Loosening the bandage is beneficial because it decreases pressure.

Clients who have casts applied to the lower extremities must be monitored for complications. Which findings during assessment of the extremities of these clients are indicative of a complication? Select all that apply. 1. warmth 2. numbness 3. skin desquamation 4. generalized discomfort 5. prolonged capillary refill

2, 5 rationale: Numbness is a neurologic sign that should be reported immediately, because it indicates pressure on the nerves and blood vessels. Compression of arterial vessels results in a prolonged return of blood to the periphery after compression of capillaries and is indicative of compromised circulation. Warmth is an expected reaction to a new cast. Desquamation becomes apparent after a cast is removed. Some degree of discomfort is expected after cast application.

A client with multiple fractures is admitted to the hospital. What is a nurse in the proficient stage expected to do in this situation? 1. Assess the client carefully for potential complications related to multiple fractures 2. Ensure that the client is transferred to the orthopedic unit to undergo appropriate treatment 3. Coordinate with all the appropriate members of the healthcare team when providing client care 4. Identify the basic principles of providing orthopedic care and let a higher-level nurse perform client care

3 rationale: A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple past experiences. Because this nurse focuses on managing care, the nurse is expected to coordinate with all the appropriate members of a healthcare team to provide proper client care. An expert-level nurse is able to look at a situation intuitively; in this case, a nurse at this level is expected to assess the client for potential complications related to multiple fractures. A nurse at the competent stage is able to understand the organization and specific care required for the type of client in question; in this case, the nurse is expected to understand that the client requires orthopedic care and should be transferred to the orthopedic unit for proper treatment. A nurse at the advanced beginner level is expected to identify the basic principles of providing orthopedic care. However, a nurse of a higher level should provide client care.

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign that is unique to a fat embolus? 1. oliguria 2. dyspnea 3. petechiae 4. confusion

3 rationale: At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also, elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these adaptations only occur with a fat embolism. Oliguria, dyspnea, and confusion are signs of an embolus but are not specific to a fat embolus.

The nurse is caring for a client with a distal femoral shaft fracture. For which clinical indicator unique to a fat embolus should the nurse assess the client? 1. oliguria 2. dyspnea 3. petechiae 4. confusion

3 rationale: At the time of fracture or orthopedic surgery, fat globules may move from bone marrow into the bloodstream; also, increased catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization from fat globules, petechiae are noted in buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these indicators occur only with fat embolism. Oliguria is a clinical finding of an embolus but is not specific to a fat embolus. Dyspnea is not a clinical manifestation of a fat embolus, but an embolus. Confusion is a clinical manifestation of an embolus but is not specific to a fat embolus.

A 14-year-old adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent and encourage movement? 1. Allowing friends to visit daily 2. Explaining that some pain is inevitable 3. Encouraging decision-making regarding care 4. Setting specific limits regarding this behavior

3 rationale: Decision-making fosters and supports independence, a developmental need of the adolescent. It also increases a sense of self-worth and control. Allowing friends to visit daily promotes social interaction, not movement. Although it may be true pain is inevitable, explaining this is not a motivating intervention. Setting specific limits is confrontational; limit-setting meets the security needs of young children.

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? 1. Confronting the client about substance abuse 2. Avoiding calling attention to the client's drug abuse 3. Determining the amount and time of last use of the substance 4. Realizing that this client will need more pain medication than a nonabuser

3 rationale: Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists, but this is not the priority. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would, but this is not the priority.

A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the crutch walking? 1. Pulse of 100 beats/min and deep respirations 2. Flushed skin and slowed respirations 3. Profuse diaphoresis and rapid respirations 4. Blood pressure of 150/88 mm Hg and shallow respirations

3 rationale: Diaphoresis and tachypnea indicate that the client has exceeded tolerance for the activity. Pulse of 100 beats/min and deep respirations are expected adaptations to activity. Flushed skin is an expected response to activity; respirations will increase in depth rather than become slow. An increase in blood pressure is an expected response to activity; respirations probably will increase in depth and rate.

A client is admitted to the hospital after falling and fracturing a hip. The primary healthcare provider applies a Buck boot with traction until surgery to replace the head of the femur with a prosthesis can be performed. What action can the nurse take to ensure that the Buck traction is being applied correctly? 1. Fit the spreader bar snugly around the foot. 2. Position the boot so it extends 3 inches (7.6 cm) above the ankle. 3. Hang the weight to apply traction, but limit it to 10 lb (4.5 kg). 4. Cover the malleoli with tape to adequately secure the weights to the leg.

3 rationale: Eight pounds of weight commonly is applied to maintain adequate traction. Weight greater than 5 to 10 lb (2.3 to 4.5 kg) causes excessive tension on the skin, leading to damage. The spreader bar should be wide enough to keep materials away from the malleoli. The Buck boot should extend to the area just below the knee. Tape is unnecessary when a Buck boot is used.

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which unique clinical indicator can help the nurse identify a fat embolus? 1. anxiety 2. restlessness 3. pinpoint red spots on the chest 4. decreased arterial oxygen level

3 rationale: Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae) on the chest and conjunctiva of the eye. Anxiety occurs in both fat embolism and thromboembolism. There often is a feeling of dread or impending doom. Restlessness and confusion from cerebral hypoxia occur in both fat embolism and thromboembolism. The arterial oxygen may be decreased in both fat embolism and thromboembolism.

Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait? 1. Elbows should be kept in rigid extension. 2. Most of the weight should be supported by axillae. 3. The client must be able to bear weight on both legs. 4. The affected extremity should be kept off the ground.

3 rationale: In the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. Thus, both legs must be able to bear some weight. Although the arms are extended to allow the hands to bear weight, the elbows are not maintained in this position. Pressure on the axillae may damage nerves in the area. Both extremities must be able to bear weight.

A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. What should the nurse teach the client to do to use the walker? 1. Place the back legs of the walker about 10 inches (25.4 cm) in front of the feet, shift the body weight to the walker, and step forward. 2. Move the walker about 8 inches (20.3 cm) forward while stepping forward to the walker, with body weight on the walker and both legs. 3. Place the walker flat on the floor with the front legs about 12 inches (30.5 cm) in front of the feet, shift the body weight to the walker, and step forward to take initial steps. 4. Move the walker about 10 inches (25.4 cm) in front of the feet with only the front legs of the walker on the floor, then step forward and put the walker flat.

3 rationale: Placing the walker flat on the floor provides stability; putting weight on the walker equalizes weight bearing on the upper and lower extremities. Placing the back legs of the walker about 10 inches (25.4 cm) in front of the feet, shifting the body weight to the walker, and stepping forward places the walker too far in front of the client for safe transfer of body weight; also, all four legs should be flat on the ground. It is not possible to move the walker and have it bear weight at the same time; the walker should be flat on the ground when the client is stepping forward. All four points of the walker should be flat on the ground when the client is stepping forward.

What should be the priority action of the nurse who is caring for a client with a leg in traction? 1. assessing the mobility 2. assessing the injured bone 3. assessing the skin integrity 4. assessing the muscle spasm

3 rationale: The nurse caring for a client with traction of a leg should first assess the skin integrity because skin breakdown may develop quickly. Assessing for mobility and the injured bone are performed after assessing for skin integrity. Assessment for muscle spasms is done after assessing the skin integrity.

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client? 1. Sit up in a chair to help strengthen back muscles. 2. Keep the unaffected leg in extension and abduction. 3. Exercise the triceps, finger flexors, and elbow extensors. 4. Use a trapeze frequently to strengthen the biceps muscles.

3 rationale: The triceps, finger flexors, and elbow extensors are used in crutch walking and therefore need strengthening. Although back muscles keep the person erect, the most important muscles for walking with crutches are the triceps, elbow extensors, finger flexors, and the muscles in the unaffected leg. Keeping the unaffected leg in extension and abduction will do nothing to promote crutch walking. A pushing, not a pulling, motion is used with crutches; the triceps, not the biceps, are used.

A 19-year-old adolescent is admitted to the emergency department with multiple fractures and potential internal injuries. The client's history reveals multiple drug abuse for the past 8 months. When caring for this client, the nurse determines that the most serious life-threatening responses usually result from withdrawal from which drug? 1. Heroin 2. Methadone 3. Barbiturates 4. Amphetamines

3 rationale: Withdrawal from central nervous system depressants, such as barbiturates, is associated with more severe morbidity and mortality. Symptoms begin with anxiety, shakiness, and insomnia; within 24 hours convulsions, delirium, tachycardia, and death may occur. Withdrawal from heroin or methadone is rarely life threatening, but it does cause severe discomfort, including abdominal cramping and diarrhea. Withdrawal from amphetamines is rarely life threatening, but it causes severe exhaustion and depression.

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply. 1. bedwetting 2. thumb-sucking 3. difficulty consoling 4. underdevelopment for age 5. demands for physical closeness

3, 4 rationale: Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress, as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years. Abused children do not seek physical closeness because their needs for comfort have not been met in the past.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? 1. Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history 2. Assess vital signs, obtain a history, and arrange for emergency x-ray films 3. Conduct a thorough physical assessment, assess vital signs, and cover open wounds 4. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

4 rationale: A thorough physical assessment is too time-consuming initially; open wounds can be covered at a later time. Initial rapid assessment will determine priorities of care and subsequent actions. IV therapy and transfusions will be prescribed, but baseline data are needed to assess the client's present condition and the significance of future responses. Although important, obtaining a history and x-ray films can be postponed until bleeding is controlled and injuries are assessed.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1. Weak upper arm strength and impaired stamina 2. Weight bearing as tolerated and unilateral paralysis 3. Partial weight bearing on the affected extremity and kyphosis 4. Strong upper arm strength and non-weight bearing on the affected extremity

4 rationale: A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1. fever and chest pain 2. positive Homans sign 3. loss of sensation in the operative leg 4. tachycardia and petechiae over the chest

4 rationale: Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? 1. 5% Dextrose and lactated Ringer solution 2. 0.9% normal saline solution 3. Total parenteral nutrition 4. Whole blood products

4 rationale: The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood.