CH. 67 MUSCULOSKELETAL SYSTEM

28. When using cementless components in a joint replacement surgery what must the patient have for the surgery to be successful? A) Inaccurate fitting B) Faulty cement C) Presence of healthy bone D) Inadequate blood supply

PRESENCE OF HEALTHY BONE **Accurate fitting and the presence of healthy bone with adequate blood supply are important in the use of cementless components. Cement, faulty or otherwise, is not used in a cementless procedure.

4. The nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what preventive measures would the nurse implement? A) Do not remove the crusting around the pin insertion site. B) Encourage the patient to push up with the elbows when repositioning. C) Encourage the patient to perform ankle and calf muscle exercises once a shift. D) Assess the pin insertion site every 8 hours.

ASSESS THE PIN INSERTION SITE EVERY 8 HRS **The pin insertion site should be assessed every 8 hours for inflammation and infection. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Ankle and calf exercises should be done 10 times an hour while awake.

9. A male patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take? A) Assume he's anxious about discharge, and administer pain medication. B) Assess the surgical site and affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Suspect a wound infection, and monitor the patient's temperature and vital signs.

ASSESS THE SURGICAL SITE AND AFFECTED EXTREMITY ** Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication don't address the cause of the pain. Sudden severe pain isn't normal after hip replacement. Wound infections are usually distinguished by purulent drainage.

3. A patient is admitted to the unit in traction for a fractured proximal femur. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russell's traction B) Dunlop's traction C) Buck's extension traction D) Cervical head halter

BUCK'S EXTENSION TRACTION **Buck's extension is used for fractures of the proximal femur. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Russell's is used for lower leg fractures. Cervical head halters are used to treat back pain.

10. The nursing instructor is talking with her class about cast care when one of the students asks what the nurse should do if a patient sticks something inside a cast to scratch whatever itched. What action would the instructor tell the students it would be appropriate for the nurse to take? A) Allow the patient to continue to scratch inside the cast with a pencil. B) Give the patient a sterile metal object to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists. D) Obtain an order for a sedative, such as diazepam (Valium), to prevent the patient from scratching.

ENCOURAGE THE PATIENT TO AVOID SCRATCHING, AND OBTAIN AN ORDER FOR DIPHENHYDRAMINE (BENADRYL) IF SEVERE ITCHING PERSISTS **Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Patients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching.

31. What does plantar flexion demonstrate? A) Function of the plantar nerve B) Function of the tibial nerve C) Function of the radial nerve D) Function of the peroneal nerve

FUNCTION OF THE TIBIAL NERVE **Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate function of the plantar nerve, radial nerve, or peroneal nerve.

40. When caring for a patient who underwent orthopedic surgery, the goals would include what? A) Improving function B) Restoring immobility C) Giving anti-inflammatory medications D) Doing passive range-of motion exercises

IMPROVING FUNCTION **The goals include improving function by restoring motion and stability and relieving pain and disability. The goals do not include restoring immobility, giving anti-inflammatory medications, or giving passive range-of-motion exercises.

5. You are caring for a patient who has had a right hip replacement. What should the nurse follow when caring for a patient who has just had hip replacement surgery? A) Keep the hips in abduction. B) Keep hips flexed at 95 degrees. C) Elevate the head of the bed to a high Fowler's position. D) Seat the patient in a low chair.

KEEP THE HIPS IN ABDUCTION **The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.

7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what should the nurse do? A) Maintain the leg in an abducted position. B) Maintain the leg in an adducted position. C) Maintain the leg in a neutral position. D) Maintain the leg with the hip flexed greater than 90 degrees.

MAINTAIN THE LEG IN AN ABDUCTED POSITION **After receiving a hip prosthesis, the affected leg should be kept abducted. Adduction (option B) may dislocate the hip. Option C would be correct if an internal fixation device was used. Option D is incorrect because the hip must not be flexed more than 90 degrees for the first 2 months and even less than that for the first 10 days.

8. A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords. B) Release the weights and replace them immediately after positioning. C) Lift the traction and the patient during repositioning. D) Maintain the same degree of traction tension.

MAINTAIN THE SAME DEGREE OF TRACTION TENSION **Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. Options A, B, and C are incorrect because it isn't appropriate to increase traction tension or release or lift the traction during repositioning.

18. A nurse is admitting an 83-year-old female patient who arrives at the emergency department by ambulance after falling on the ice outside her senior citizens' housing facility. The admitting diagnosis is right hip fracture. What would be most important for the nurse to assess? A) Leg shortening B) Complaints of pain C) Neurovascular compromise D) Internal or external rotation

NEUROVASCULAR COMPROMISE **Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

20. The nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms best represent peroneal nerve injury? A) Numbness and burning of the foot B) Numbness and burning of the hand C) Cyanotic toes D) Inadequate capillary refill

NUMBNESS AND BURNING OF THE FOOT **Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis and decreased capillary refill are signs of inadequate circulation.

11. A patient who underwent a total hip replacement is being routinely turned. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Use measures other than turning to prevent pressure ulcers. C) Prevent internal rotation of the affected leg. D) Keep the hip flexed by placing pillows under the patient's knee.

PREVENT INTERNAL ROTAITON OF THE AFFECTED LEG **External rotation and abduction of the hip helps to prevent dislocation of a new hip joint. Internal rotation and adduction should be avoided. Postoperative total hip replacement patients may be turned onto the unaffected side. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary.

16. The nurse is preparing instructions for a patient who is going home with a cast on his leg. What teaching point is most critical to emphasize in the teaching session? A) Using crutches properly B) Exercising joints above and below the cast, as ordered C) Avoiding walking on a leg cast without the physician's permission D) Reporting signs of impaired circulation

REPORTING SIGNS OF IMPAIRED CIRCULATION **Although all of these interventions are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The patient should learn to use his crutches properly to avoid nerve damage. The patient may exercise above and below the cast, as the physician orders. The patient should be told not to walk on the cast without the physician's permission.

37. A patient has been in skeletal traction for 3 weeks. The nurse caring for the patient knows to assess what every 4 to 8 hours? A) Bladder B) Respiratory status C) Neurovascular status D) Skin

RESPIRATORY STATUS **The nurse auscultates the patient's lungs every 4 to 8 hours to assess respiratory status and teaches the patient deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. The nurse would not assess the bladder, the skin, and the neurovascular status of the patient every 4 to 8 hours.

6. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the knee replacement surgical site. The affected leg has a decreased pedal pulse. What would be the most appropriate nursing diagnosis for this patient? A) Risk for infection B) Risk of peripheral neurovascular dysfunction C) Ineffective health maintenance D) Self-esteem disturbance

RISK OF PERIPHERAL NEUROVASCULAR DYSFUNCTION **The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of peripheral neurovascular dysfunction. Therefore options A, C, and D are incorrect.

1. The nurse is caring for a patient who has had a plaster leg cast applied. Immediately post-application, the nurse should inform the patient that: A) The cast will cool in 5 minutes. B) The cast should be covered with a towel. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.

THE CAST WILL ONLY HAVE FULL STRENGTH WHEN DRY **A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The initial cooling occurs in about 15 minutes after application of the cast.

32. You are caring for a patient in skeletal traction. What do you caution the patient about to prevent bony fragments from moving against one another? A) Removing the traction for bathing B) Repositioning with assistance C) Turning side to side D) Coughing

TURNING SIDE TO SIDE **To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance.

38. You are assuming care of a 16-year-old patient who is in skeletal traction following a motor vehicle accident. You take shift report and find out that the patient avoids using the urinal and bedpan because they "embarrass him." When you assess the patient you find that the patient's temperature is 101.5°F and his blood pressure and pulse are elevated. What would the nurse suspect? A) Sacral skin breakdown B) Infected pin sites C) Urinary infection D) Urinary incontinence

URINARY INFECTION **Incomplete emptying of the bladder related to positioning in bed can result in urinary stasis and infection.

36. As an orthopedic nurse you know that there are several immobility-related complications that a patient can acquire when they are placed in traction. What complications might a patient in traction acquire? A) Anorexia B) Thromboemboli C) Urinary stasis D) Diarrhea E) Lactose intolerance

URINARY STASIS **Immobility-related complications may include pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, urinary tract infections, and venous thromboemboli formation.

29. A patient is scheduled for a total knee replacement. The surgeon explains the technique of creating a "bloodless" field for the surgery to the patient. What does this entail? A) Intermittent autotransfusion B) Postoperative blood salvage C) Intraoperative blood salvage with reinfusion D) Use of a pneumatic tourniquet

USE OF A PNEUMATIC TOURNIQUET **Blood is conserved during surgery to minimize loss. During orthopedic surgery on a limb (eg, total knee replacement [TKR]), a pneumatic tourniquet may be applied to produce a "bloodless field." This technique has the advantages of keeping the surgical field dry, minimizing blood loss, and providing some additional limb anesthesia. Intraoperative blood salvage with reinfusion is used when a large volume of blood loss is anticipated. Postoperative blood salvage with intermittent autotransfusion also reduces the need for blood transfusion.

24. The physician writes an order to discontinue skeletal traction on your patient. Once the traction is discontinued what occurs to immobilze and support the healing bone? A) A walking boot is applied. B) A cast is applied. C) Patient is shown how to use crutches. D) Patient is instructed in the use of a cane.

A CAST IS APPLIED **When skeletal traction is discontinued, the extremity is gently supported while the weights are removed. The pin is cut close to the skin and removed by the physician. Internal fixation, casts, or splints are then used to immobilize and support the healing bone. A walking boot would not be used after skeletal traction, nor would crutches or a cane until the bone has healed completely.

34. Orthopedic surgery can be used to correct a variety of orthopedic conditions. What conditions can be corrected by orthopedic surgery? (Mark all that apply.) A) Joint disease B) Stable fractures C) Tumors D) Inflammed tissue E) Nectotic tissue

A, C JOINT DISEASE, TUMORS **Conditions that may be corrected by surgery include unstabilized fractures, deformity, joint disease, necrotic or infected tissue, and tumors.

22. A nurse is caring for a patient who just had skeletal traction removed and a brace applied to their leg. What is a brace used for? (Mark all that apply.) A) Prevent additional injury B) Align body part C) Provide support D) Control movement E) Prevent deformity

A, C, D PREVENT ADDITIONAL INJURY, PROVIDE SUPPORT, CONTROL MOVEMENT **Braces (ie, orthoses) are used to provide support, control movement, and prevent additional injury. They are custom fitted to various parts of the body.

27. Patients who do not have mechanical prophylaxis and pharmacologic prophylaxis have a higher incidence of DVT than patients who do. What is mechanical prophylaxis for a DVT? A) Pneumatic tourniquet B) Anti-embolism stockings C) CPM machine D) Thigh-high TEDs

ANTI-EMBOLISM STOCKINGS **The incidence of deep vein thrombosis (DVT) is 48% for patients who have not had any type of VTE preventive measures instituted, which includes mechanical prophylaxis (eg, anti-embolism stockings) and pharmacologic prophylaxis (eg, antithrombotic medications). Therefore options A, C, and D are incorrect.

21. A patient has suffered a muscle strain and is complaining of severe pain. The nurse knows that most pain can be relieved by what? A) Dangling the involved part B) Applying cold packs C) Immobilizing the involved part D) Administering anti-inflammatories as prescribed

APPLYING COLD PACKS **Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Immobilizing the involved part is a distractor for this question.

33. A student nurse is helping with the initial assessment of an 85-year-old patient. What can the student do to ensure that shearing forces are avoided? (Mark all that apply.) A) Puts on foam boots three or more times a day. B) Inspect and provide skin care q shift. C) Palpate the area of the traction tapes daily. D) Provides back care at least q 2 hours. E) Give massage q shift.

B, C, D INSPECT AND PROVIDE SKIN CARE Q SHIFT, PALPATE THE AREA OF THE TRACTION TAPES DAILY, PROVEDES BACK CARE AT LEAST Q 2 HRS. ** During the initial assessment, the nurse identifies sensitive, fragile skin (common in older adults). The nurse also closely monitors the status of the skin in contact with tape or foam to ensure that shearing forces are avoided. The nurse performs the following procedures to monitor and prevent skin breakdown: removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three times a day. A second nurse is needed to support the extremity during the inspection and skin care. The nurse palpates the area of the traction tapes daily to detect underlying tenderness, and provides back care at least every 2 hours to prevent pressure ulcers. The patient who must remain in a supine position is at increased risk for development of a pressure ulcer. Special mattress overlays (eg, air-filled, high-density foam) are used to prevent pressure ulcers.

12. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. What may this be a sign of? A) Edema B) A pressure ulcer C) Compartment syndrome D) Disuse syndrome

COMPARTMENT SYNDROME **Compartment syndrome may manifest as unrelenting, uncontrollable pain. Discomfort from edema may be relieved with elevation of the limb; pain from ulcers is usually relieved when ulceration occurs. Disuse syndrome may result in disuse atrophy.

39. You are caring for a patient admitted to the orthopedic unit in skeletal traction. You know that this patient is at increased risk for a DVT. What would you do to decrease the risk of DVT in this patient? A) Pretend to ride a bicycle while you lay in bed. B) Allow the patient to assist with passive range-of-motion exercises. C) Encourage the patient to perform active ROM exercises on the affected leg. D) Do foot and ankle exercises every 1 to 2 hours while awake.

DO FOOT AND ANKLE EXERCISES EVERY 1-2 HOURS WHILE AWAKE **Venous stasis that predisposes the patient to venous thromboembolism occurs with immobility. The nurse teaches the patient to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. You would not encourage active range-of-motion exercise nor would you assist in passive range-of-motion exercises.

23. You are caring for a patient who is in skeletal traction. What is most important to do frequently when caring for a patient in skeletal traction to maintain effective traction? A) Check the traction apparatus to see that the ropes are in the wheel grooves of the pulleys. B) Make sure that the weights hang freely. C) Make sure that the knots in the rope are tied securely. D) Evaluate patient's position, because slipping down in bed results in ineffective traction.

EVALUATE PATIENT'S POSITION, BECAUSE SLIPPING DOWN IN BED RESULTS N INEFFECTIVE TRACTION **The nurse evaluates the patient's position, because slipping down in bed results in ineffective traction. Though all options are correct nursing interventions when caring for a patient in skeletal traction, options A, B, and C are incorrect because they do not maintain effective traction.

19. A patient you are caring for undergoes a total hip replacement. You are getting ready to review the patient teaching that you presented over the past few days. What statement made by the patient would indicate to the nurse that the patient requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."

I WILL NEED MY HUSBAND TO ASSIS ME IN GETTING OFF THE LOW TOILET SEAT AT HOME **To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used 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. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.

35. A patient is undergoing preoperative respiratory testing to provide baselines of respiratory function for the postoperative period. A patient you are caring for has preoperative testing that indicates he is at increased risk for respiratory complications. What therapy would you initiate to aid in the prevention of respiratory complications for your patient? A) Respiratory exercises B) Incentive spirometer C) Chest percussion D) Broad-spectrum antibiotics

INCENTIVE SPIROMETER **If the patient history and baseline assessment indicate that the patient is at risk for development of respiratory complications, specific therapies (eg, use of incentive spirometer) may be indicated. Chest percussion, respiratory exercises, and broad-spectrum antibiotics would not be started preoperatively

15. The nurse assesses the patient in traction frequently. What signs or symptoms would the nurse assess for when assessing for a DVT in a traction patient? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf

INCREASED WARMTH OF THE CALF **Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

26. A patient comes to the clinic complaining of pain at the site of their hip replacement. The patient tells the nurse they had their hip replacement surgery 3 years ago. On assessment the nurse notes the area around the surgical scar is erythematous and edematous. What would the nurse suspect? A) Infection at the surgical site that has spread from another site in the body B) A delayed surgical infection C) An acute infection D) A host infection

INFECTION AT THE SURGICAL SITE THAT HAS SPREAD FROM ANOTHER SITE IN THE BODY **Infections occurring more than 2 years after surgery are attributed to the spread of infection through the bloodstream from another site in the body. Delayed surgical infections may appear 4 to 24 months after surgery and may cause return of discomfort in the hip. Acute infections may occur within 3 months after surgery and are associated with progressive superficial infections or hematomas. A host infection is a distracter for this question

17. A patient with a right tibial fracture is being discharged home after having a cast applied. The nurse gives instructions to the patient and his family. What instruction should the nurse provide in relationship to the patient's cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a knitting needle to scratch itches inside the cast. D) A foul smell from the cast is normal.

KEEP YOUR RIGHT LEG ELEVATED ABOVE HEART LEVEL **The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

13. The nursing instructor in the skills lab at the nursing school is showing a group of nursing students how to apply traction. What is an appropriate example of proper traction use? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be resting against the bed's footboard. D) Skeletal traction may be removed.

KNOTS IN THE ROPE SHOULD NOT BE RESTING AGAINST PULLEYS **Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.

2. An 18-year-old male patient broke his arm in a skateboarding accident. The arm was put in an arm cast. The patient states that he is unable to straighten his fingers. The nurse notes that the patient is experiencing Volkmann's contracture, which is due to what? A) Obstructed arterial blood flow to the forearm and hand B) Obstructed venous blood flow from the forearm and hand C) The cast being applied too loosely D) Muscle spasm of the forearm

OBSTRUCTED ARTERIAL BLOOD FLOW TO THE FOREARM AND HAND **Volkmann's contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. Therefore options B, C, and D are incorrect.

14. What statement about skeletal traction is most accurate? A) Traction weight is increased as muscles relax. B) Often balanced traction is used. C) Skeletal traction is used until the fracture is healed. D) Pins are attached to the muscle of the affected limb.

OFTEN BALANCED TRACTION IS USED **Balanced traction is often used with skeletal traction. As the muscles relax, the amount of weight is decreased, pins are inserted through the bone, and skeletal traction is discontinued when callus formation is evident by radiograph.

25. As skeletal traction overcomes the shortening spasms of affected muscles what happens to the skeletal traction? A) Nothing changes B) More weight is added to keep the limb in proper alignment C) Weight is removed to promote healing D) Weight is balanced between heavier and lighter

WEIGHT IS REMOVED TO PROMOTE HEALING **Skeletal traction frequently uses 7 to 12 kg (15 to 25 lb) to achieve the therapeutic effect. The weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing.

30. You are working with a student nurse to set up traction on a patient with Buck's traction. How often do you need to assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift

WITHIN 30 MINUTES THEN EVERY 1-2 HOURS **After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours. Therefore options B, C, and D are incorrect