Chapter 37
The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the-knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate
A) A tourniquet
A patient has returned to the postsurgical unit from the PACU after an above-the knee amputation of the right leg. Results of the nurses initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurses initial action? A) Apply a tourniquet. B) Elevate the residual limb. C) Apply sterile gauze. D) Call the surgeon
A) Apply a tourniquet
A nurse is caring for a patient who had aright below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
A) Encouraging the patient to turn from side to side and to assume a prone position
An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patients description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury? A) Lateral collateral ligament injury B) Medial collateral ligament injury C) Anterior cruciate ligament injury D) Posterior cruciate ligament injury
A) Lateral collateral ligament injury
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes E) Muscle weakness
A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A) Patient can demonstrate safe use of assistive devices. B) Patient has a healed, nontender, nonadherent scar. C) Patient can perform activities of daily living independently. D) Patient is free of pain
A) Patient can demonstrate safe use of assistive devices
A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome
A) Post-traumatic arthritis
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patients cast.
A) Prepare the patient for opening Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.
A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply. A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions D) Use of corticosteroids as ordered E) Weight-bearing exercise
A) Regular bone density testing B) A high-calcium diet C) Use of falls prevention precautions E) Weight-bearing exercises
A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness
A) Risk for Infection
A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patients active participation in self-care. In order to determine the patients ability to be an active participant in selfcare, the nurse should prioritize assessment of what variable? A) The patients attitude B) The patients learning style C) The patients nutritional status D) The patients presurgical level of function
A) The patients attitude
The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patients concern? A) You will eventually be able to withstand full weight-bearing after the amputation. B) You will have minimal weight-bearing on this extremity but you'll be taught how to use an assistive device. C) You likely will not be able to use this extremity but you will receive teaching on use of a wheelchair. D) You will be fitted for a prosthesis which may or may not allow you to walk
A) You will eventually be able to withstand full weight-bearing after the amputation.
A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A. "Make sure you don't bring your knees close together." B. "Try to lie as still as possible for the first few days." C. "Try to avoid bending your knees until next week." D. "Keep your legs higher than your chest whenever you can."
A. "Make sure you don't bring your knees close together."
The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client? A. "Push the knees into the mattress." B. "Lie prone in bed." C. "Contract the buttock muscles." D. "Bend the knees."
A. "Push the knees into the mattress."
The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A. A tourniquet B. A syringe preloaded with vitamin K C. A unit of packed red blood cells, placed on ice D. A dose of protamine sulfate
A. A tourniquet
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale-appearing calf
A. Increased warmth of the calf
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? 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 braced by the footboard of the bed. D. Skeletal traction may be removed for brief periods to facilitate the client's independence.
A. Knots in the rope should not be resting against pulleys.
A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client? A. Place a pillow between the legs. B. Turn the client on the surgical side. C. Avoid flexion of the right hip. D. Keep the right hip adducted at all times.
A. Place a pillow between the legs
A client is involved in a motorcycle accident and injures an arm. The health care provider diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A. Posttraumatic arthritis B. Fat embolism syndrome (FES) C. Osteomyelitis D. Compartment syndrome
A. Posttraumatic arthritis
A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Obtain a prescription for a different analgesic. C. Encourage the client to wiggle and move the fingers. D. Petal the edges of the client's cast.
A. Prepare the client for opening or bivalving of the cast.
A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for infection B. Risk for ineffective role performance C. Risk for perioperative positioning injury D. Risk for powerlessness
A. Risk for infection
A nurses assessment of a patients knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what? A) A first-degree strain B) A second-degree strain C) A first-degree sprain D) A second-degree sprain
B) A second-degree strain Asecond-degree strain involves tearing of muscle fibers and is manifested by notable loss of load-bearing strength with accompanying edema, tenderness, muscle spasm, and ecchymosis. A first-degree strain reflects tearing of a few muscle fibers and is accompanied by minor edema, tenderness, and mild muscle spasm, without noticeable loss of function. However, this patient states a loss of function. A sprain normally involves twisting, which is inconsistent with the patients overuse injury.
A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb
B) Applying ice C) Compression dressings D) Resting the affected extremity F) Elevating the injured limb
An older adult patient has fallen in her home and is brought to the emergency department by ambulance with asuspected fractured hip. X-rays confirm afracture of the left femoral neck. When planning assessments during the patients presurgical care, the nurse should be aware of the patients heightened risk of what complication? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia
B) Avascular necrosis
A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture? A) Compression B) Compound C) Impacted D) Transverse
B) Compound Also called an open fracture
A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do? A) Elevate the affected extremity to shoulder level when at rest. B) Engage in exercises that strengthen the unaffected muscles. C) Apply topical anesthetics to accessible skin surfaces as needed. D) Avoid using analgesics so that further damage is not masked.
B) Engage in exercises that strengthen the unaffected muscles.
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.
B) Explain the risks of flexion contracture to the patient.
The orthopedic nurse should assess for signs and symptoms of Volkmann's contracture if a patient has fractured which of the following bones? A) Femur B) Humerus C) Radial head D) Clavicle
B) Humerus
A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure
B) Maintaining spinal alignment
A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.
B) Monitor temperature and pulses of the affected extremity.
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? A) Administer analgesics as required. B) Place a pillow between the patients legs when turning. C) Maintain prone positioning at all times. D) Encourage internal and external rotation of the affected leg
B) Place a pillow between the patients legs when turning.
An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing
B) The importance of adhering to the prescribed treatment and rehabilitation regimen
A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client'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 clean object to scratch itches inside the cast." D. "A foul smell from the cast is normal after the first few days."
B. "Keep your right leg elevated above heart level"
A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury? A. A first-degree strain B. A second-degree strain C. A first-degree sprain D. A second-degree sprain
B. A second-degree strain
A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A. Taking an opioid analgesic as prescribed B. Applying a cold pack to the injured site C. Performing passive ROM exercises D. Applying a heating pad to the affected muscle
B. Applying a cold pack to the injured site
A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. A. Massage B. Applying ice C. Compression dressings D. Resting the affected extremity E. Corticosteroids F. Elevating the injured limb
B. Applying ice C. Compression dressings D. Resting the affected extremity F. Elevating the injured limb
A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The nurse assesses that the indwelling urinary catheter was removed one hour ago in the post-anesthesia care unit and that the client has not yet voided. Which action should the nurse take? A. Inform the primary provider promptly. B. Ask if the client needs to void. C. Perform intermittent catheterization. D. Obtain an order to reinsert the indwelling urinary catheter
B. Ask if the client needs to void
An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication? A. Osteomyelitis B. Avascular necrosis C. Phantom pain D. Septicemia
B. Avascular necrosis
A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to perform ADLs independently. B. Client is able to perform transfers safely. C. Client is able to weight-bear equally on both legs. D. Client is able to demonstrate full ROM of the affected hip.
B. Client is able to perform transfers safely.
Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. Open B. Comminuted C. Intra-articular D. Greenstick
B. Comminuted
A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A. Compression B. Compound C. Impacted D. Transverse
B. Compound
A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Elevate the affected extremity to shoulder level when at rest. B. Engage in exercises that strengthen the unaffected muscles. C. Apply topical anesthetics to accessible skin surfaces as needed. D. Avoid using analgesics so that further damage is not masked.
B. Engage in exercises that strengthen the unaffected muscles
The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action? A. Inform the surgeon of this finding. B. Explain the risks of flexion contracture to the client. C. Transfer the client to a sitting position. D. Encourage the client to perform active ROM exercises with the residual limb.
B. Explain the risks of flexion contracture to the client.
A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription? A. Traction must temporarily be aligned in a slightly different direction. B. Extra weight is needed initially to keep the limb in proper alignment. C. A lighter weight should be initially used. D. Weight will temporarily alternate between heavier and lighter weights.
B. Extra weight is needed initially to keep the limb in proper alignment
A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A. Preventing skin breakdown B. Maintaining spinal alignment C. Maximizing function D. Preventing increased intracranial pressure
B. Maintaining spinal alignment
A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A. Perform chest physiotherapy once per shift and as needed. B. Teach the client to perform deep breathing and coughing exercises. C. Administer prophylactic antibiotics as prescribed. D. Administer nebulized bronchodilators and corticosteroids as prescribed.
B. Teach the client to perform deep breathing and coughing exercises
A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurses most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound
C) Arterial blood gases
A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist? A) Nerve damage is associated with third-degree strains. B) Compartment syndrome is associated with third-degree strains. C) Avulsion fractures are associated with third-degree strains. D) Greenstick fractures are associated with third-degree strains.
C) Avulsion fractures are associated with third-degree strains.
A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A) Sprain B) Strain C) Contusion D) Dislocation
C) Contusion
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity
C) Disturbed Body Image
A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patients need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the overbed trapeze D) Encouraging the patient to log roll side to side once per hour
C) Encouraging frequent use of the overbed trapeze
A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C) Fat embolism syndrome
A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patients fracture likely be graded? A) Grade I B) Grade II C) Grade III D) Grade IV
C) Grade III
A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism (VTE)
C) Inadequate immobilization
A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.
C) Increase fluid intake and perform prescribed foot exercises.
Six weeks after an above-the-knee amputation (AKA),a patient returns to the outpatient office for a routine postoperative checkup. During the nurses assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.
C) Take opioid analgesics as ordered.
A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction? A. "Skeletal traction temporarily stabilizes the fracture before surgery." B. "Weights are attached to the leg using a boot." C. "Traction involves passing a pin through the bone." D. "Light weights must be used with skeletal traction."
C. "Traction involves passing a pin through the bone"
A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? A. Nerve damage is associated with third-degree strains. B. Compartment syndrome is associated with third-degree strains. C. Avulsion fractures are associated with third-degree strains. D. Greenstick fractures are associated with third-degree strains.
C. Avulsion fractures are associated with third-degree stains
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. A. Systemic infection B. Complex regional pain syndrome C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism
C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism
A client with a total hip replacement has developed decreased breath sounds What is the nurse's best action? A. Place the client on bed rest. B. Request an antitussive medication from the health care provider. C. Encourage use of the incentive spirometer. D. Assess for signs and symptoms of systemic infection.
C. Encourage use of the incentive spirometer
A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Allow the client to gently scratch inside the cast with a pencil. B. Give the client a sterile tongue depressor to use for scratching instead of the pencil. C. Provide a fan to blow cool air into the cast to relieve itching, D. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.
C. Provide a fan to blow cool air into the cast to relieve itching
A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Administration of prophylactic antibiotics B. Total parenteral nutrition (TPN) C. Use of a pressure-relieving mattress D. Use of a Foley catheter until discharge
C. Use of a pressure-relieving mattress
An emergency department patient is diagnosed with a hip dislocation. The patients family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurses statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patients pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.
D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.
Radiographs of a boys upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick
D) Greenstick Incomplete fractures that result in the bone being broken on one side, while the other is bent.
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following? A) Apply heat for the first 24 to 48 hours after the injury. B) Maintain the ankle in a dependent position. C) Exercise hourly by performing rotation exercises of the ankle. D) Keep an elastic compression bandage on the ankle.
D) Keep an elastic compression bandage on the ankle.
A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patients health care is holistic C) Facilitate the patients adjustment to a new body image D) Promote the patients highest possible level of function
D) Promote the patients highest possible level of function
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms? A) Subluxated right hip B) Right hip contusion C) Hip strain D) Traumatic hip dislocation
D) Traumatic hip dislocation
A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do? A) Elevate the arm above the shoulder 3 to 4 times daily. B) Avoid moving the elbow, wrist, and fingers until bone remodeling is complete. C) Engage in active range of motion using the affected arm. D) Use the arm for light activities within the range of motion.
D) Use the arm for light activities within the range of motion.
A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client 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."
D. "I will need my husband to assist me in getting off the low toilet seat at home."
A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take? A. Administer pain medication. B. Massage the client's calf. C. Apply antiembolic stockings. D. Notify the health care provider.
D. Notify the health care provider
A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A. Maximize the efficiency of care. B. Ensure that the client's health care is holistic. C. Facilitate the client's adjustment to a new body image. D. Promote the client's highest possible level of function
D. Promote the client's highest possible level of function
A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A. Warm the client's foot and determine whether circulation improves. B. Reposition the client with the affected foot dependent. C. Reassess the client's neurovascular status in 15 minutes. D. Promptly inform the primary care provider.
D. Promptly inform the primary care provider
A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client? A. The cast will feel cool to touch for the first 30 minutes. B. The cast should be wrapped snuggly with a towel until the client gets home. C. The cast should be supported on a board while drying. D. The cast will only have full strength when dry.
D. The cast will only have full strength when dry.
