Fractures, Femoral Fractures

Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following? 1. Signs of skin pressure in the groin area. 2. Evidence of decreased breath sounds. 3. Skin breakdown behind the heel. 4. Urine retention.

1. The nurse should assess for signs of skin pressure in the groin area because the Thomas splint, which is a half-ring that slips over the thigh and suspends the lower extremity in direct skeletal traction, may cause discomfort, pressure, or skin irritation in the groin. The nurse always assesses respirations as part of routine vital signs, but assessing for evidence of decreased breath sounds is not a routine assessment related directly to the Thomas splint. The head of the bed can be elevated to facilitate breathing, but not more than 25 degrees, to avoid continually moving the client toward the foot of the bed from the weight of the traction. The nurse always assesses for pressure areas on dependent parts, but assessing for skin breakdown behind the heel is not a routine assessment related directly to the Thomas splint, in which the heel is free of any contact with padding or metal parts of the Pearson attachment for the balanced suspension traction. The client who is in a Thomas splint is able to use a bedpan to urinate, especially the fracture bedpan for a female client and the urinal for a male. Urine retention should not be a special assessment directly related to the Thomas splint, but it may be a client-specific assessment.

When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. 1. The drug can be used if the person is allergic to aspirin. 2. Acetaminophen does not affect platelet aggregation. 3. This drug causes little or no gastric distress. 4. Acetaminophen exerts a strong anti-inflammatory effect. 5. The client should have the International Normalized Ratio (INR) checked regularly.

1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not affect platelet aggregation and the client does not need to have coagulation studies (such as INR). Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-inflammatory effects.

Which of the following client statements identifies a knowledge deficit about cast care? 1. "I'll elevate the cast above my heart initially." 2. "I'll exercise my joints above and below the cast." 3. "I can pull out cast padding to scratch inside the cast." 4. "I'll apply ice for 10 minutes to control edema for the first 24 hours."

3. Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes during the first 24 hours helps to reduce edema.

A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate? 1. Greater trochanter skin checks. 2. Pin site inspection. 3. Neurovascular checks proximal to the splint. 4. Foot movement evaluation.

3. Neurovascular checks should be performed distal or past the site of the splint, not proximal or above the site of the splint, at least every 4 hours. An injury or compromise to the peripheral nervous innervation or blood flow will reflect a change on the site of the splint after the pathway from the heart and brain. Checking the skin over the greater trochanter is appropriate because the half-ring of the Thomas splint can slide around the greater trochanter area where the traction is applied; it should be checked routinely along with other areas at high risk for pressure necrosis, such as the fibular head, ischial tuberosity, malleoli, and hamstring tendons. Inspecting the pin site is appropriate because any drainage or redness might indicate an infection in the bone in which the pin is inserted. Immediate treatment is imperative to avoid osteomyelitis and possible loss of the limb. Evaluation of the foot for movement is important to obtain neuromuscular-vascular data for assessment in comparison with the baseline data of the affected extremity and with the opposite extremity to detect any compromise of the client's condition.

When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? 1. The area proximal to the fracture. 2. The actual fracture site. 3. The area distal to the fracture. 4. The opposite extremity for baseline comparison.

3. The nursing assessment is first focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood flow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular flow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.

A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first: 1. Review the results of culture and sensitivity testing of the wound. 2. Look for the presence of a pressure dressing over the wound. 3. Determine if the client has increased pain from exposed nerve endings. 4. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.

1. The wound was left open with a three-way drainage system in place to irrigate the debrided wound with normal saline or an antibiotic. Before the debridement, a sample of the wound would be taken for culture and sensitivity testing so that an organism-specific antibiotic could be administered to prevent possible serious sequelae of osteomyelitis. Therefore, the nurse should review the results of the culture and sensitivity report. A pressure dressing would not be applied to an open wound. Rather, a wet-to-dry dressing most likely would be used. There should not be increased pain related to the exposure of nerve endings in the subcutaneous tissue of the wound that was left open to the environment. The bleeding of vessels should be controlled as it would have been if the wound had been closed. Therefore, additional vessel bleeding should not be a problem.

The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? 1. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. 2. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. 3. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. 4. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches.

2. A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead.

After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching? 1. To align injured bones. 2. To provide long-term pull. 3. To apply 25 lb of traction. 4. To pull weight with a boot.

4. Skeletal traction is not used to pull weight with a boot. Skeletal traction involves the insertion of a wire or a pin into the bone to maintain a pull of 5 to 45 lb on the area, promoting proper alignment of the fractured bones over a long term.

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care? 1. Use of a fracture bedpan. 2. Checks for redness over the ischial tuberosity. 3. Elevation of the head of bed no more than 25 degrees. 4. Personal hygiene with a complete bed bath.

4. The client with a femoral fracture in balanced suspension traction should not be given a complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed, such as with a trapeze triangle. Use of a fracture bedpan is appropriate. A fracture bedpan is lower, and it is easier for the client to move on and off the bedpan without altering the line of traction. Checking for areas of redness or pressure over all areas in contact with the traction or bed, including the ischial tuberosity, is important to prevent possible skin breakdown. The client should be positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.

A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? 1. Crackles. 2. Jaundice. 3. Generalized edema. 4. Dark, scanty urine.

4. The client with compartment syndrome may release myoglobin from damaged muscle cells into the circulation. This becomes trapped in the renal tubules, resulting in dark, scanty urine, possibly leading to acute renal failure. Crackles may suggest respiratory complications; jaundice suggests liver failure; and generalized edema may suggest heart failure. However, these are not associated with compartment syndrome.

Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? 1. Acute respiratory distress syndrome. 2. Migraine-like headaches. 3. Numbness in the right leg. 4. Muscle spasms in the right thigh.

1. Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.

A client with a fractured right femur has not had any immunizations since childhood. Which of the following biologic products should the nurse administer to provide the client with passive immunity for tetanus? 1. Tetanus toxoid. 2. Tetanus antigen. 3. Tetanus vaccine. 4. Tetanus antitoxin.

4. Passive immunity for tetanus is provided in the form of tetanus antitoxin or tetanus immune globulin. An antitoxin is an antibody to the toxin of an organism. Administering tetanus toxoid, antigen, or vaccine would provide active immunity by stimulating the body to produce its own antibodies.

A client has a Pearson attachment on the traction setup. Which of the following is the purpose of this attachment? 1. To support the lower portion of the leg. 2. To support the thigh and upper leg. 3. To allow attachment of the skeletal pin. 4. To prevent flexion deformities in the ankle and foot.

1. The Pearson attachment supports the lower leg and provides increased stability in the overall traction setup. It also makes it easier to maintain correct alignment. It does not support the thigh and upper leg or prevent flexion deformities in the ankle and foot. It is not attached to the skeletal pin.

The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client: 1. "You can sit up whenever you want." 2. "You must lie flat on your back most of the time." 3. "You can turn your body." 4. "You must lie on your stomach."

1. The client can sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction. Maintenance of even, sustained traction decreases the chance that the bandage or traction strap might slip and cause compression or stress on the nerves or vascular tracts, resulting in permanent damage. The client does not have to remain flat but may adjust the head of the bed to varying degrees of elevation while remaining in the supine position. The client should not turn his body to another position because the bandage may slip.

The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect? 1. Lack of infection. 2. Reduction in itching. 3. Relief of muscle spasms. 4. Decrease in nervousness.

3. Methocarbamol is a muscle relaxant and acts primarily to relieve muscle spasms. It has no effect on microorganisms, does not reduce itching, and has no effect on nervousness.

The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis? 1. The client assists as much as possible in his care, demonstrating increased participation over time. 2. The client allows the nurse to complete his care in an efficient manner without interfering. 3. The client allows his wife to assume total responsibility for his care. 4. The client allows his wife to complete his care to promote feelings of usefulness.

1. The client's assisting as much as possible in his care and increasing participation over time indicate that the client has accomplished self-care by gaining a sense of control. If the client lets the nurse complete his care without interfering, his behavior would indicate passivity, possibly from denial or depression. If the client allows his wife to assume total responsibility for his care or to complete his care, he still has a self-care deficit and a successful outcome has not been reached.

A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? 1. Presence of a distal pulse. 2. Pain with a pain rating scale. 3. Vital sign changes. 4. Potential for drug tolerance.

1. The nurse should assess the client's ability to move her toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's complaints suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.

The client with a fractured femur is upset and agitated about her injury and its treatment. She says, "How can I stay like this for weeks? I can't even move!" Which of the following is the most appropriate nursing diagnosis? 1. Impaired physical mobility related to traction. 2. Ineffective coping related to prolonged immobility. 3. Deficient diversional activity related to prolonged hospitalization. 4. Activity intolerance related to impaired mobility.

2. Based on the client's statements, Ineffective coping is the most appropriate nursing diagnosis because the client is voicing frustration about the current situation and her inability to move. The nurse should seek ways to help the client adjust to and cope with her present state of immobility. Emphasis should be placed on what the client can do to care for herself, such as participating in her daily care and exercises to maintain muscle strength, to help her maintain some control over her situation. The data do not support a diagnosis of Impaired mobility, Deficient diversional activities, or Activity intolerance.

The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following reflects the best interpretation of these findings? 1. Pulmonary emboli. 2. Osteomyelitis. 3. Fat emboli. 4. Urinary tract infection.

2. Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

Which of the following interventions would be least appropriate for a client who is in a double hip spica cast? 1. Encouraging the intake of cranberry juice. 2. Advising the client to eat large amounts of cheese. 3. Establishing regular times for elimination. 4. Having the client dangle at the bedside.

2. The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged and the client should be encouraged to drink at least 2,500 mL/ day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following? 1. Use herbal supplements. 2. Eat a diet high in protein and vitamins C and D. 3. Ask the health care provider for a change of antibiotics. 4. Encourage frequent passive range-of-motion to the affected extremity.

2. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/ 50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/ minute and shallow. The nurse interprets these findings as indicating which of the following? 1. Expected common adverse effects. 2. Hypersensitivity reaction. 3. Possible habituating effect. 4. Hemorrhage from gastrointestinal irritation.

3. Hypotension, tachycardia, and depressed respirations are signs of high levels of ingestion of muscle relaxants, and the client may be developing a habit of taking this drug for a prolonged period. The potential for abuse should be considered when large doses of a muscle relaxant such as carisoprodol are taken for prolonged periods. Expected common adverse effects would include drowsiness, fatigue, lassitude, blurred vision, headache, ataxia, weakness, and gastrointestinal upset. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.

A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy? 1. The client adducts the affected leg every 2 hours. 2. The client rolls the affected leg away from the body's midline twice per day. 3. The client performs isometric exercises to the affected extremity three times per day. 4. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/ day.

3. Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless ordered by the physician; it will not prevent muscle atrophy.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? 1. Transfer the client to a cart with manually suspended traction. 2. Call the surgeon to request an order to temporarily remove the traction. 3. Send the client on his bed with extra help to stabilize the traction. 4. Remove the traction and send the client on a cart.

3. The nurse should send the client to the operating room on his bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.