Musculoskeletal 2

A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture?

3. Lie on the abdomen 30 minutes four times daily.

A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. What should the nurse explain is the benefit of bearing most of the weight on the unaffected leg?

2. Will help maintain the strength of the unaffected limb

When should the nurse begin the process of rehabilitation when a client is scheduled for an appointment?

1. Before the surgery

A client had an above-the-knee amputation of the left leg because of trauma from a motor vehicle collision. The health care provider orders ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's first intervention?

2.Determine if the client has ever used crutches before

What should be included in the nurse's instructions to help a client prepare for walking with crutches?

2.Exercices with or without weights to strengthen the muscles of the upper extremeties

Which crutch gait should the nurse teach the client wearing a prosthesis after a single leg amputation?

2.Four-point

After an above-the-knee amputation of a leg,a client reports pain in the foot that is no longer there. What should the nurse include about phantom limb pain in a discussion with the client?

2.Nerve endings in the limb are still intact and react to stimuli

The nurse is supervising a new graduate RN caring for a patient with a fracture of the right ankle who is at risk for complications of immobility. For which action should the supervising nurse intervene? 1. Encouraging the patient to go from a lying to a standing position 2. Administering pain medication before the patient begins exercises 3. Explaining to the patient and family the purpose of the exercise program 4. Reminding the patient about the correct use of crutches

1. Encouraging the patient to go from a lying to a standing position

A nurse is caring for a client in the evening after the client has had a below-the-knee amputation. What action should be implemented by the nurse?

1. Elevate the foot of the bed

A client has a total hip replacement. Which clinical indicators of pulmonary embolism indicate that the plan to prevent postoperative thrombus formation has been ineffective? SATA

2. Unilateral chest pain 4. Sudden onset of SOB

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

1. Restlessness

A client has a long leg cast. What instructions should the nurse give the client in preparation for crutch walking?

4. Do exercices in bed to strengthen the upper extremeties

The care plan for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor?

4. Loss of blood supply to the head of the femur

Which position should a nurse avoid placing a client who had surgery for a total hip replacement?

3. Orthopneic

For what clinical findings of compromised circulation should the nurse assess in a client with a long leg cast? SATA

2. Swelling of the toe 5. Prolonged capillary refill

A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?

2. Toes for mobility

A client is in skin traction while awaiting surgery for repair of a fractures 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"

After an open reduction and internal fixation of a fractured hip, what assessments of the client's affected leg should the nurse make? SATA

1. Skin temperature 3. Sensation in the toes 5. Presence of pedal pulse

A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention initially should receive the lowest priority?

1. Teaching residual limb care

A client has a total knee replacement, and a continuous passive motion device is being used. The nurse concludes that the teaching was effective when the client states, "The goal of therapy is to:

1.improve joint flexion."

After the nurse receives change-of-shift report, which patient should be assessed first? 1. A 42-year-old patient with carpal tunnel syndrome who reports pain 2. A 64-year-old patient with osteoporosis awaiting discharge 3. A 28-year-old patient with a fracture who reports that the cast is tight 4. A 56-year-old patient with a left leg amputation who reports phantom pain

3. A 28-year-old patient with a fracture who reports that the cast is tight

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately?

3. The traction weights are resting on the floor.

Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses?

3. Amplitude and symmetry

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?

3. Compress and release the client's toenails

A client is admitted with a fracture of the neck of the femur.In what position should the nurse maintain the client's affected extremity?

3. Internal rotation with extension of the knee and hip

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate?

3. On the client's left side

What should the nurse do to control edema of the residual limb 1 week after a client has an above-the-knee amputation?

3. Rewrap the elastic bandage as necessary

Which principles should the nurse consider when assisting a client with crutches to learn the four-point gait?

3. The client must be able to bear weight on both legs

Which clinical indicator should the nurse expect to identify when assessing a client with a fracture of the neck of the femur?

3.Shortening of the affected extremity with external rotation

What should the nurse do to promote early and efficient ambulation after a client has a midthigh amputation?

3.Turn the client to the prone position routinely

A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has an order for ambulation with slight weight-bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive device does the nurse expect the HCP to order for this client?

4. Standard walker

What instructions should the nurse provide when the client is allowed out of bed after an above-the-knee amputation?

1. Keep the hip in extension and alignment

A nurse is caring for a client with a fracture of the head of the femur. The HCP places the client in a Buck extension. What explanation does the nurse give the client for why the traction is being used?

1. Reduces muscle spasms

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the purpose of the traction?

1. Relieve muscle spasm and pain

A nurse suspects the development of compartment syndrome for a client who has sustained blunt trauma to the forearm. For which early sign of compartment syndrome should the nurse assess the client? 1) Warm skin at the site of injury 2) Escalating pain in the fingers. 3) Rapid capillary refill in affected hand 4) Bounding radial pulse in the injured arm

2) Escalating pain in the fingers.

A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.

2. The patient appears confused.

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 counter-traction is ordered. Hoe does the nurse increase the countertraction?

3. Use a slight trendelenburg position

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

4. Press the end of the residual limb against a pillow periodically