prep-37
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 need to remember not to cross my legs. It's such a habit." "I'll need to keep several pillows between my legs at night."
"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? "I will wear a boot with weights attached." "Metal pins will go through my skin to the bone." "A belt will go around my pelvis and weights will be attached." "The traction can be removed once a day so I can shower."
"Metal pins will go through my skin to the bone." Explanation: In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.
A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first? "My pain is a 3." "My toes are stiff." "My toes are pink." "My cast is still wet.
"My toes are stiff." Explanation: Compartment syndrome is characterized by neurovascular compromise. Stiffness of the toes may be a preliminary finding that the client is having trouble with motor function.
A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? Volkmann's contracture Compartment syndrome Subluxation Sprain
"The physical therapist will likely help you get up using a walker the day after your surgery." Explanation: Clients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however.
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? An open reduction A total knee replacement A fasciotomy A total hip replacement
A fasciotomy Explanation: A treatment option for compartment syndrome is fasciotomy.
A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply. a)The left leg is shorter than the right. b)The skin over the left hip is warm. C)The client is able to bend the knee but not move toes. D)The skin of the lower left leg is pale. E)Limited range of motion of the left hip.
A,b, d Explanation: The leg may be shorter than its unaffected counterpart as a result of the displacement of one of the articulating ones. ROM is limited. Evidence of soft tissue injury includes swelling, coolness (not heat), numbness, tingling, and pale or dusky color of the distal tissue. The client will not be able to bend the knee but will be able to move the toes.
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 a tourniquet. Apply sterile gauze. Call the surgeon. Elevate the residual limb.
Apply a tourniquet. Explanation: The nurse should apply a tourniquet in the event of postsurgical hemorrhage. Elevating the limb and applying sterile gauze are likely insufficient to stop the hemorrhage. The nurse should attempt to control the immediate bleeding before contacting the surgeon.
A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? Keeping the client from sliding to the foot of the bed Keeping the ropes over the center of the pulley Ensuring that the weights hang free at all times Assessing the extremity for neurovascular integrity
Assessing the extremity for neurovascular integrity Explanation: Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.
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? Encourage the client to push up with the elbows when repositioning. Assess the pin insertion site every 8 hours. Apply occlusive dressings to the pin sites. Encourage the client to perform isometric exercises once a shift.
Assessing the extremity for neurovascular integrity Explanation: Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.
Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? Column A Column B Column C Column D
Column B Explanation: Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.
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 Spiral Oblique Compound
Compound Explanation: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin
A client comes to the emergency department and reports localized pain and swelling in the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. What will the nurse most likely suspect? -Sprain Strain Contusion Fracture
Contusion Explanation: The client's description of blunt trauma by a baseball bat and localized pain in conjunction with swelling and ecchymosis would most likely suggest a contusion. A fracture would be manifested by pain, loss of function, deformity, swelling, and spasm. A sprain would be manifested by pain and swelling; ecchymosis may appear later. A strain is characterized by inflammation, local tenderness, and muscle spasms.
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? Blood pressure of 140/90 mm Hg Crackles in the lung bases Client complains of pain in the affected rib area when taking a deep breath Heart rate of 94 beats/minute
Crackles in the lung bases Explanation: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
The nurse in an orthopedic clinic is caring for a new client. What sign or symptom would lead a nurse to suspect that a client has a rotator cuff tear? Difficulty lying on affected side Ability to stretch arm over the head Pain worse in the morning Minimal pain with movement
Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.
Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? Fat embolism syndrome (FES) Complex regional pain syndrome (CRPS) Avascular necrosis (AVN) Disseminated intravascular coagulation (DIC)
Disseminated intravascular coagulation (DIC) Explanation: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. AVN of the bone occurs when the bone loses its blood supply and dies. CRPS is a painful sympathetic nervous system problem. FES occurs when the fat globules released when the bone is fractured occludes the small blood vessels that supply the lungs, brain, kidneys, and other organs.
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? Elevating the stump for the first 24 hours Maintaining the client on complete bed rest Applying heat to the stump as the client desires Removing the pressure dressing after the first 8 hours
Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.
A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client? Minimal pain in the left arm Fingers on the left hand are swollen and cool Cast edges are rough, with skin irritation present Presence of a normal popliteal pulse
Fingers on the left hand are swollen and cool Explanation: Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected.
Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture? Open reduction Arthrodesis Joint arthroplasty Total joint arthroplasty
Open reduction Explanation: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is: Risk for avascular necrosis of the joint Situational low self-esteem Disturbed body image Risk for ineffective therapeutic regimen management
Risk for ineffective therapeutic regimen management Explanation: The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.
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? Similar to "muscle cramps" Sore and aching Sharp and piercing A dull, deep, boring ache
Sharp and piercing Explanation: The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.
Which term refers to an injury to ligaments and other soft tissues surrounding a joint? Sprain Subluxation Dislocation Strain
Sprain Explanation: A sprain is caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.
Which may occur if a client experiences compartment syndrome in an upper extremity? Callus Subluxation Whiplash injury Volkmann's contracture
Volkmann's contracture Explanation: If compartment syndrome occurs in an upper extremity, it may lead to Volkmann's contracture, a claw-like deformity of the hand resulting from obstructed arterial blood flow to the forearm and hand. A whiplash injury is a cervical spine sprain. Callus refers to the healing mass that occurs with true bone formation after a fracture. Subluxation refers to a partial dislocation.
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? Ropes freely moving over pulleys Pulleys without evidence of the obstruction Body aligned opposite to line of traction pull Weights hanging and touching the floor
Weights hanging and touching the floor Explanation: When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.
The type of fracture described as having one side of the bone broken and the other side bent would be: spiral. greenstick. oblique. transverse.
greenstick. Explanation: A greenstick fracture is the type of fracture described as having one side of the bone broken and the other side bent. An oblique fracture occurs at an angle across the bone. A spiral fracture is a fracture that twists around the shaft of the bone. A transverse fracture is a fracture that is straight across the bone.
A fracture is considered pathologic when it -results in a fragment of bone being pulled away by a ligament or tendon and its attachment. -occurs through an area of diseased bone. -presents as one side of the bone being broken and the other side being bent. -involves damage to the skin or mucous membranes.
occurs through an area of diseased bone. Explanation: Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.
