Quiz 9
B
A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should examine the client for which of the following manifestations of dislocation of the hip prosthesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg
C
An 80-year-old man with diabetes has had vascular problems with his feet and lower legs for 10 years and is scheduled for a left below-the-knee amputation. Which remark by the patient indicates an understanding of the procedure? a. "I am glad this amputation will end my diabetic problems." b. "After they have hacked my leg, I won't be able to drive." c. "If this heals well, how long until I get a prosthesis?" d. "I hate that my left knee is going to be useless without a foot."
staged guillotine
An amputation of a gangrenous limb that is left open for 10 days before closure is classified as a(n) _____ amputation.
C
An older adult patient is at risk for constipation after sustaining a pelvic fracture. Which nutritional suggestion by the nurse is most appropriate? a. Select food with high sodium content. b. Avoid foods high in dietary fiber. c. While immobilized, drink at least 2 to 3 L of fluids daily. d. Include milk products at every meal.
D
An older patient who sustained a fractured hip and femur in a motor vehicle accident is to be in Russell traction for several weeks. What should be the focus of care for the nurse? a. Offering frequent distractions b. Encouraging nutrition c. Offering pain relief d. Preventing deep vein thrombosis (DVT)
A, D, E, B, C
Arrange the process of stair climbing with crutches in the correct sequence: (Separate letters by a comma and space as follows: A, B, C, D.) A. Body weight is supported with crutches. B. Crutches are moved to the next step. C. The affected leg moves to the next step. D. The unaffected leg is moved to the next step. E. Body weight is transferred to the unaffected leg.
B
Two days after surgery for a crushed pelvis, a certified nursing assistant (CNA) reports that the patient is complaining of a shortness of breath and is demonstrating signs of confusion and restlessness. What should a nurse suspect, from these signs alone, that the patient has developed? a. Impending shock b. Fat embolus c. Anxiety d. Neurovascular compromise
B
What are late signs of hemorrhage in the postoperative period after an amputation? a. Restlessness and increased respirations b. Cyanosis and hypotension c. Confusion and seizures d. Headache and hypertension
D
What should a nurse teach an older patient with a newly casted Colles fracture? a. Apply cool compresses to the cast. b. Let the hand and arm dangle to increase the drainage. c. Keep the hand immobile to reduce swelling. d. Move the shoulders to reduce contractures.
A, B, C, D
Which major situational occurrences might lead to amputations? (Select all that apply.) a. Trauma b. Disease c. Tumors d. Congenital defects e. Carelessness
D
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age 78 years B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago
D
A nurse is told that a patient has a compound comminuted fracture. What characteristic of the bone in this type of fracture causes the nurse to be concerned? a. It is bent but not completely broken, and the bent piece protrudes through the skin. b. It is compressed, and bone pieces protrude through the skin. c. It is twisted, and the fragments are separated. d. It is broken into two or more pieces, and bone fragments protrude through the skin.
B, C, E, A, D
A nurse uses a diagram to show the process of a fractured bone healing. (Arrange the options in the appropriate sequence. Separate letters by a comma and space as follows: A, B, C, D.) A. Ossification B. Hematoma C. Fibrocartilage D. Consolidation E. Callus
D
A patient who has a below-the-elbow prosthesis shows the home health care nurse the residual limb, which is red, edematous, and warm to the touch. What should the nurse instruct this patient to do? a. Apply soothing lotion to the residual limb before replacing the prosthesis. b. Dampen the prosthetic limb sock to hydrate and cool the residual limb. c. Pad the socket with lamb's wool and replace the prosthesis. d. Leave the prosthesis off and notify physician.
A, B, D, E
How should a nurse modify a teaching plan for an older adult who has had an above-the-knee amputation? (Select all that apply.) a. Offer smaller units of information at a time. b. Increase time for learning. c. Place less emphasis on chronic health problems. d. Clarify the reality of phantom pain. e. Include frequent repetition.
D
A nurse is caring for a client who had an above-the-knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? A. Remove the initial pressure dressing. B. Encourage use of cold therapy. C. Question whether the pain is real. D. Administer an antiepileptic medication.
A, C, D, E
A nurse is collecting data from a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestation of compartment syndrome?(Select all that apply.) A. Intense pain when the client's left foot is passively moved B. Capillary refill of 3 sec on the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication
B, C, D, E
A nurse is collecting data from a client who is scheduled to undergo a right knee arthroscopy. The nurse should expect which of the following findings? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion
pathological
A fracture that occurs because of osteoporosis is classified as a(n) _____ fracture.
C
The verbalization of microvascular precautions is a criterion for measuring the achievement of which outcome? a. Adequate circulation in the replanted limb b. Pain relief c. Patient knowledge of therapeutic measures d. Adjustment to change in appearance and function
B
A 78-year-old retired teacher with a history of osteoporosis has fallen in her bathroom and sustained a subcapital femoral fracture. She is scheduled for an open reduction and internal fixation (ORIF) procedure in the morning. Which type of traction will most likely be implemented? a. Bryant b. Buck c. Pelvic d. Crutchfield tongs
D
A child comes to the school nurse with his index finger partially amputated and hanging by a shred of skin and muscle. What is the best action by the nurse? a. Flush the hand with warm water and wrap it in a towel. b. Carefully cut the skin holding the finger and wrap the finger and hand in a clean towel. c. Pinch the finger to stop the bleeding and take the child to the hospital. d. Wrap the hand and finger securely and place it on an ice water-filled plastic bag.
C
A home health care nurse suspects a neuroma in a patient who had an above-the-knee amputation 1 month earlier. Which complaint by the patient led the nurse to suspect a neuroma? a. Area of swelling and bruising on distal portion of residual limb b. Prickling sensation over residual limb c. Sharp severe pain in the residual limb d. Area of numbness on distal portion of residual limb
disarticulation
A nurse clarifies that the precise term for the patient's amputation, which will be through the knee joint, is called _____.
A
A nurse in an ambulatory clinic is caring for a client who has facial trauma to the nose. Which of the following actions should the nurse take first? A. Determine the client's ability to take deep breaths. B. Place a cold compress on the nasal area. C. Palpate the nasal area for crepitation. D. Offer the client an analgesic medication.
A, B, C, D
A nurse is assisting with preparing a presentation to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the follow information should the nurse provide? (Select all that apply.) A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care. E. Advise clients to wait 2 hr after taking pain medication before driving.
B
A nurse is aware that a patient who is having his leg amputated is also having a prosthesis fitted during at the same time as the surgery. Which fact should the preoperative teaching plan include? a. Extra preoperative medications will be needed. b. A rigid dressing will be applied to accommodate the prosthesis. c. A series of temporary prostheses will be put in place before the permanent one. d. Wiring the residual limb will be needed to ensure acceptance of the prosthesis.
A, B, C, E
A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? (Select all that apply.) A. Palpate the residual limb for warmth. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in a circular manner using gauze. E. Monitor for feelings of body image changes.
B
A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? A. Sensation of heat on the surface of the cast B. Paresthesias of the extremity C. Pruritus of the extremity D. Musty odor noted from cast materials
C
A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? A. Use a hair dryer on a cool setting to blow air into the cast. B. Ask the provider to bivalve the cast. C. Provide the client with a sterile cotton swab to rub the affected skin. D. Wrap the extremity with a dry heating pad.
B
A nurse is caring for a client who has a right hip fracture. Which of the following immobilization devices should the nurse expect the provider to prescribe for this client? A. Skeletal traction B. Buck's traction C. Halo traction D. Bryant's traction
C
A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse provide the client? A. "Keep your arm bent at the elbow." B. "Use a pillow to prop your shoulder up close to your ear." C. "Hold your arm against the side of your body." D. "Position your arm with the shoulder at a 90-degree angle."
B
A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the pain? A. Prone without use of pillows B. Semi-Fowler's with a pillow under the knees C. High-Fowler's with the knees flat on the bed D. Supine with the head flat
C
A nurse is caring for a patient that has undergone replantation of a body part. What might the saliva of leeches be used to treat in this patient? a. Inadequate arterial blood flow b. Venous insufficiency c. Venous congestion d. Increased arterial blood flow
C
A nurse is caring for a patient with a recent below-the-knee amputation. What should the nurse recommend to this patient to prevent the loss of calcium and protein? a. Drink 1 to 2 L of fluid daily. b. Ingest at least four milk products each day. c. Ambulate 30 minutes a day. d. Take vitamin supplements daily.
A
A nurse is collecting data from a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? A. Altered mental status B. Reduced bowel sounds C. Swelling of the toes distal to the injury D. Pain with passive movement of the foot distal to the injury
A, D, E
A nurse is collecting data from a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Heberden's nodes B. Swelling of all joints C. Small body frame D. Enlarged joint size E. Limp when walking
B, C, D, E
A nurse is collecting data from a client who has suspected osteoporosis. Which of following findings are risk factors for osteoporosis? (Select all that apply.) A. History of consuming one glass of wine daily B. Loss in height of 2 in (5.1 cm) C. Body mass index (BMI) of 18 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance
A
A nurse is collecting data from a client who is 24 hr postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? A. Report of muscle spasms B. Inability to get dressed without assistance C. Report of feelings of anger D. Refusal to look at the affected limb
A, C, D, E
A nurse is collecting data from clients during a health screening at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply.) A. A 40-year-old client who has been taking prednisone for 4 months B. A 30-year-old client who jogs 3 miles daily C. A 45-year-old client who takes phenytoin for seizures D. A 65-year-old client who has a sedentary lifestyle E. A 70-year-old client who has smoked for 50 years
C
A nurse is conducting a safety seminar and reminds the audience that upper extremity amputations are most frequently caused by trauma. Which population has the highest incidence of this type of amputation? a. School-aged girls b. School-aged boys c. Young men d. Young women
A, C, D, E
A nurse is contributing to the plan of care for a client who is postoperative following an arthroscopy of the knee. Which of the following should the nurse recommend for inclusion in the plan? (Select all that apply.) A. Check color and temperature of the extremity. B. Apply warm compresses to incision sites. C. Place pillows under the extremity. D. Administer analgesic medication. E. Monitor pulse and sensation in the foot.
A, C, E
A nurse is contributing to the plan of care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include? (Select all that apply.) A. Check for bruising. B. Administer aspirin prior to the procedure. C. Determine whether the client takes a muscle relaxant. D. Instruct the client to flex muscles during needle insertion. E. Expect swelling, redness, and tenderness at the insertion sites.
C
A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as a treatment for this condition? A. Misoprostol B. Dantrolene C. Celecoxib D. Colchicine
B
A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following actions should the nurse include? A. Limit any type of exercise to the residual limb for the first 48 hr after surgery. B. Position the client prone several times each day. C. Wrap the residual limb in a figure-eight pattern. D. Encourage sitting in a chair during the day.
B
A nurse is providing care for a client who h vertebroplasty of the thoracic spine. Which the following actions should the nurse take A. Apply heat to the puncture site. B. Place the client in a supine position. C. Turn the client every 1 hr. D. Ambulate the client within the first hour postprocedure.
B
A nurse is reinforcing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? A. White bread B. Kale C. Apples D. Brown rice
A, C, E
A nurse is reinforcing discharge teaching for a client who had a total hip arthroplasty. Which of the following information should the nurse include? (Select all that apply.) A. Clean the incision daily with soap and water. B. Turn the toes inward when sitting or lying. C. Sit in a straight-backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.
A, B, C, E
A nurse is reinforcing discharge teaching on home safety for a client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove throw rugs in walkways. B. Use prescribed assistive devices. C. Remove clutter from the environment. D. Wear soft-bottomed shoes. E. Maintain lighting of doorway areas.
A
A nurse is reinforcing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse reinforce? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated. C. Airborne precautions are used during wound care. D. Expect paresthesia distal to the wound.
A, D, E
A nurse is reinforcing preoperative teaching for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse review with the client? (Select all that apply.) A. Encourage complete autologous blood donation. B. Sit in a low reclining chair. C. Instruct the client to roll onto the operative hip. D. Use an abductor pillow when turning the client. E. Instruct the client on the use of incentive spirometry.
B, C, E
A nurse is reinforcing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (Select all that apply.) A. "Avoid damage or moisture to the cast on your arm. B."Inspect your incision daily for indications of infection." C. "Apply ice packs to the area for the first 24 hours." D. "Keep your arm in a dependent position." E. "Perform isometric exercises."
C
A nurse is reinforcing preoperative teaching with a client who is scheduled for total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding the teaching? A. "I will begin using a continuous movement machine on my knee one day after surgery." B."I should avoid taking NSAID medications for pain." C. "I should wear elastic stockings on both of my legs." D. "I will have a small weight attached to my leg to hold the joint in place after surgery."
A
A nurse is reinforcing teaching about residual limb care for a client who has a below the knee amputation. Which of the following instructions should the nurse include? A. Use a mirror to examine all areas of the residual limb daily. B. Adjust the prosthesis twice a week. C. Change bandages once a week. D. Wrap the residual limb with compression tape by using a circular motion daily.
A, D, E
A nurse is reinforcing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (Select all that apply.) A. Engage in regular exercise including walking. B. Sit for up to 10 hr each day to rest the back. C. Maintain weight within 25% of ideal body weight. D. Create a smoking cessation plan. E. Wear low-heeled shoes.
B
A nurse is reinforcing teaching with a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include? (Select all that apply.) A. Apply heat to joints to alleviate pain. B. Ice inflamed joints for 30 min following activity. C. Reduce the amount of exercise done on days with increased pain. D. Prop the knees with a pillow while in bed. E. Active range of motion is more effective than passive.
D
A nurse is reinforcing teaching with a client who is going to have a bone scan. Which of the following statements should the nurse include? A."You will receive an injection of a radioactive isotope when the scanning procedure begins." B. "You will be inside a tube-like structure during the procedure. C. "You will need to take radioactive precautions with your urine for 24 hours after the procedure." D. "You will have to urinate just before the procedure."
A, B, C, E
A nurse is reinforcing teaching with a client about how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply.) A. "I will clean the pins more often if drainage from the pins increases. B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." D. "I will move my leg by lifting the device in the middle. E. "I will report increased redness at the pin sites.
D
A nurse is reinforcing teaching with a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? A. "I will take the medication in the evening." B. "I will drink a full glass of milk with the medication." C. "I will take the medication at mealtime." D. "I will sit upright after taking the medication."
D
A nurse is reinforcing teaching with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? A. You will need to reply a cold back to the site three times a day B. Your provide may ask you yo walk frequently to increase circulation to the area C. You will need to limit consumption of high-protein foods D. Your provider my prescribe the central catheter line for long-term anabiotic
B, D, E
A nurse is reinforcing teaching with clients at a health fair about dual-energy x-ray absorptiometry (DXA) scans. Which of the following information should the nurse include? (Select all that apply.) A. The test requires the use of contrast material. B. The hip and spine are the usual areas the device scans. C. The scan detects osteoarthritis. D. Bone pain can indicate a need for a scan. E. Females should have a baseline scan during their 40s.
C
A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone
A, B, D
A nurse on an orthopedic unit is caring for a client following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (Select all that apply.) A. Check continuous passive motion device settings. B. Palpate dorsal pedal pulses. C. Place a pillow behind the knee. D. Elevate heels off bed. E. Apply heat therapy to incision.
D
A patient asks when he should expect to be up and walking after his below-the-knee amputation. When should the nurse assure him that most people with amputations can fully bear weight? a. 3 weeks b. 1 month c. 6 weeks d. 3 months
D
A patient has just had a plaster of Paris upper extremity cast placed because of a fractured radius. Which statement indicates that the patient understands the discharge teaching related to cast care? a. "When I get home, I will remove some of the padding if it feels tight so my fingers don't swell." b. "When I get home, I will wrap the cast in plastic so it will conserve the heat." c. "When I get home, I will use a spoon handle to scratch inside if my arm itches." d. "When I get home, I am going to rest in bed with my arm elevated above my heart."
C
A patient in a full body cast (spica) complains of nausea and abdominal distention. What potential complication should a licensed vocational nurse (LVN) suspect? a. Constipation b. Compartment syndrome c. Cast syndrome d. Shock
D
A patient who amputated his thumb in a lawnmower accident hands the emergency department nurse his thumb in a glass jar. What is the best action for the nurse to implement? a. Place the thumb in a baggie with iced lactated Ringer solution. b. Wrap the thumb in plastic wrap and place it on ice. c. Leave the thumb in the jar and place it in the refrigerator. d. Wrap the thumb in a cloth saturated with normal saline and place it in a baggie.
B
A patient who had a below-the-knee amputation 24 hours earlier is complaining of burning pain in his left foot. Which intervention is most appropriate for the nurse to implement? a. Remind the patient that it is only phantom pain. b. Medicate the patient with the prescribed pain remedy. c. Remind him that such sensations will go away in a few weeks. d. Distract the patient with conversation.
A
A patient who has osteomyelitis after multiple fractures inquires what the physician meant when he said that surgery would follow the antibiotic therapy. What is the nurse's most helpful reply to explain why this surgery will be performed? a. To remove dead bone b. To close the open draining wound c. To close the area with casting material d. To amputate
C
A patient who sustained a simple fracture of the left fibula 7 days earlier asks in what stage of bone healing he might be. What stage of healing should the nurse relay to the patient? a. Hematoma formation b. Ossification c. Callus formation d. Fibrocartilage formation
A
A patient with a crushed forearm cannot get pain relief with opioid medications. The injury is swollen, cool, and cyanotic, with weak distal pulses. What should the nurse suspect? a. Compartment syndrome b. Overwhelming infection c. Fat embolus d. Osteomyelitis
B
A patient with a fractured pelvis says that she will not ambulate because of pain. What should a nurse inform the patient can be prevented with early ambulation? a. Back injury b. DVT c. Callus formation d. Disuse syndrome
C
A patient with bilateral avascular necrosis of the hips is to walk with crutches using a four-point gait for 6 weeks after her bone decompression surgeries. Which statement would indicate that the patient understands this technique? a. "The axillary bars on the crutches should support my weight when I walk." b. "I will move both crutches and then swing my legs to the crutches—2 and 2 equals 4!" c. "I will move my right crutch and then my left leg and then the left crutch and my right leg." d. "I will move both crutches and then swing my legs through the crutches together."
B
A patient with peripheral vascular disease (PVD) and diabetes asks what he can do to help prevent an amputation. What is the best response of the nurse? a. "There is not really anything you can do to help." b. "Stopping smoking would help prevent vasoconstriction." c. "You will not need to check your blood glucose levels." d. "It is important to eat big meals so your body can heal."
A
An older woman falls down at church and immediately complains of severe pain in her left hip. Which observation is recognized as the cardinal sign of a fractured hip? a. Shortened left leg compared with the right b. Downward curled toes c. Internal rotation of the left leg d. Hematoma on the left hip
A
Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing activities on joints. Which statement by a nurse best illustrates an understanding of the appropriate use of these devices? a. "Canes provide minimal support and balance and are carried on the unaffected side." b. "When using a cane, slide it as you go to decrease the arm strain." c. "A three-point gait is used when walking with a walker." d. "When using crutches, the unaffected leg goes down the steps first."
C
During the admission of a patient scheduled for an amputation, a patient relates that she is a practicing Orthodox Jew. What arrangements are appropriate for the nurse to make for this patient? a. A veil should cover the amputated part. b. A rabbi must be present for the surgery. c. The amputated part should be buried. d. A family member should be present to read the Torah.
upper body
Preoperative exercises for a patient undergoing a lower-extremity amputation include _____ training.
prone
To reduce the possibility of hip contractures in a patient with an above-the-knee amputation, a nurse periodically places the patient in a(n) _____ position.
A, D, E
To what can delayed union of a fracture be attributed? (Select all that apply.) a. Inadequate immobilization b. Hormone replacement therapy c. Long-term use of corticosteroids d. Infection e. Poor nutrition
C
What action should a nurse implement when caring for a patient diagnosed with a compound fracture? a. Limit narcotics for 8 hours after surgery. b. Monitor the patient's respirations every hour. c. Assess for pulses distal to the injury. d. Verify that the patient is not allergic to sulfa.
D
What action should a nurse implement when dealing with the weights that are applying traction to a patient? a. Remove them to pull the patient up in bed. b. Hold them while the patient is changing positions in bed. c. Hold them for a few minutes if the patient complains of pain. d. Allow them to hang freely.
A
What controls the movement with a myoelectrically controlled prosthesis? a. Patient's muscle movement and the prosthesis b. Battery-operated muscles implanted in the prosthesis c. Motion-sensing mechanism that swings the prosthesis forward d. Internal computer chip in the prosthesis
D
What do thermographic findings of cool spots in a certain areas of the body indicate? a. Increased blood flow b. Decreased infection c. Increased infection d. Decreased blood flow
A, B
What is a closed amputation designed to do? (Select all that apply.) a. Prepare a weight-bearing limb. b. Cover the stump with tissue and muscle. c. Place sutures immediately over the bone. d. Be staged to closure. e. Be immediately ready for a prosthesis.
B
What is an appropriate outcome for a nursing diagnosis, "Anxiety, related to perceived threat of disability?" a. Comfort is increased; verbalized pain is less. b. Anxiety is relieved; the patient verbalizes concern related to disability. c. Grief is resolved; the patient expresses an acceptance of loss. d. Residual limb is cleaned; no exudate, redness, or edema is observed.
B
What is the greatest danger in the early postoperative period after an amputation? a. Infection b. Hemorrhage c. Pain d. Edema
B
What nursing action should be implemented in the postoperative care for a patient with replantation of the right thumb? a. Decreasing the temperature of the room to 70° F b. Elevating the hand but keeping it below the level of the heart c. Offering coffee, tea, or cola to help increase fluid intake d. Placing an antiembolus sleeve on the right arm
A
What routine preoperative diagnostic tests are appropriate for a patient anticipating a below-the-knee amputation? a. Pulse volume recording and white blood cell (WBC) count b. Cardiac catheterization and WBC count c. Pulse volume recording and radiographic images d. Thermography and cardiac catheterization
A, B, C, D
What should a nurse consider when selecting possible nursing diagnoses for a 32-year-old patient who is in anticipatory grieving for an upcoming bilateral above-the-knee amputation? (Select all that apply.) a. Anxiety, related to knowledge deficit of procedure b. Disturbed body image, related to loss of body part c. Sexual dysfunction, related to perceived disfigurement d. Disturbed self-image, related to loss of independence e. Activity intolerance, related to bed rest
A
What should a nurse who is documenting and reporting the signs and symptoms of an infection underneath a cast include in the medical record? a. Elevated temperature b. Tingling and decreased sensation c. Full pulses and absence of pain d. Swelling and diminished motor function
C
What special precaution should a nurse implement when assisting with the application of a short arm plaster cast? a. Dampen the skin to make the stockinette adhere. b. Tape the arm before applying the stockinette. c. Smooth the stockinette to prevent a pressure ulcer. d. Roll the stockinette tightly above and below the margins of the cast.
D
Where is the limb severed with an elbow disarticulation? a. Just above the elbow joint b. Just below the elbow joint c. Between the shoulder and elbow d. Through the elbow joint
A
Which action should a nurse implement to diminish swelling of the residual limb in the postoperative period after an above-the-knee amputation? a. Elevate the foot of the bed on blocks. b. Elevate the residual limb on pillows. c. Elevate the head of the bed 15 degrees. d. Turn the patient on the affected side.
A
Which assessment is considered abnormal when a nurse performs a neurovascular assessment on a patient in skeletal traction? a. Delayed capillary refill b. Bilateral equal pulses c. Absence of pain and swelling d. Limb is the same color as the unaffected side
B
Which assessment is of the greatest concern to a nurse when caring for a patient just admitted with a pelvic fracture? a. Pain level rating of 8 on a scale of 1 to 10 b. No urinary output for 8 hours c. Evidence of bruising along the patient's hips and buttocks d. Complaints of the need for back care from resting in bed
A, C
Which characteristics are present when crutches are properly fitted? (Select all that apply.) a. The axilla piece is 3 to 4 fingerbreadths below the axilla. b. They fit close to the axilla for secure support. c. They are measured and adjusted when the patient is in the tripod position. d. Adjusted handgrips allow for a 45-degree flexion of the elbow. e. They are padded so patient can bear weight on the axilla piece when ambulating.
C
Which finding should produce the most concern when performing pin care for a patient with an external fixator? a. Crusts around the pin b. Serous drainage on the dressing c. Purulent drainage d. Absence of pain
C
Which is true about a greenstick fracture? a. Line of the fracture goes across the bone in right angles to the longitudinal axis. b. Periosteum is not torn away from the bone. c. Fracture is incomplete, and one side is bent. d. Fracture occurred in one of the long bones of the body.
B
Which nursing diagnosis has the highest priority after surgery for the open reduction and external fixation of an ankle? a. Risk for activity intolerance b. Risk for infection c. Risk for impaired physical mobility d. Risk for constipation
B
Which patient is most appropriate for a nurse to refer to home health care? a. A married man with a laundry room on the first floor b. A single woman with a bedroom in a rooming house c. A student living in a college dormitory but going home to stay with parents d. A woman staying with her daughter and son-in-law at their one-story home
D
Which postoperative observation must be reported to the physician immediately? a. Brownish-red drainage on the dressing, which is damp b. Respirations of 20 breaths/min c. Pulse of 72 beats/min d. Bright-red bleeding
A
Why is a closed amputation usually performed? a. To create a weight-bearing residual limb b. To alleviate the effects of trauma c. To allow infection to heal and drain d. To treat a limb with gangrene
