NCLEX 10000 Musculoskeletal
An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations?
"Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." will not be helpful to the patient's frustrations.
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching?
"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additonal teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees
A client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client says:
"I will apply moist heat to my shoulder for 20 minutes three times each day." Explanation: Moist heat is a nonpharmacologic pain management strategy that may alleviate pain and reduce the dose of analgesic, if required. Heat dilates blood vessels and decreases inflammation. Lifting and circular exercises will aggravate the already-inflamed joint. Cold constricts blood vessels, and dry ice is not used on the body.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?
"Keep your right leg elevated above heart level." Explanation: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into 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
A nurse performs discharge teaching for a 58-year-old woman after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful?
"Leg-raising exercises are necessary for several months." Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.
A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time?
11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late
A client was diagnosed with chronic gouty arthritis 2 years ago. He has been taking sulfinpyrazone, 200 mg P.O. b.i.d. as maintenance therapy. How soon after administration of this drug does onset of action occur?
30 minutes Explanation: Sulfinpyrazone has a rapid onset of action, within 30 minutes after oral administration. It reaches its peak concentration within 1 to 2 hours and has a duration of action of 4 to 6 hours
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?
Administer analgesics around the clock. Explanation: Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pai
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure?
Administering large doses of I.V. antibiotics as ordered Explanation: Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.
A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain?
An exercise routine that includes range-of-motion (ROM) exercises Explanation: Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.
A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess?
Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.
A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?
Conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. Explanation: When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use
Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy?
Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.
A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include?
Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints
A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included?
Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. Explanation: A client with osteoarthritis has increased stiffness in the morning upon awakening. Exercise should be scheduled at least 1 hour after awakening. Exercising in the evening interferes with the client's ability to rest at bedtime.
A client has been diagnosed with osteoporosis after a bone density test and is asking what has caused it. Discussion of risk factors would include which of the following?
Heavy smoking, sedentary lifestyle, and high intake of carbonated drinks Explanation: Osteoporosis has been linked to heavy smoking. A sedentary lifestyle results in more osteoclastic or breakdown activity rather than bone building or osteoblastic activity. Because carbonated drinks tend to have high phosphate levels, the inverse relationship of phosphorus to calcium results in a depletion of calcium. Sunlight exposure for vitamin D and calcium intake all promote bone density. Regular exercise and weight-bearing activities also preserve bone mass. A deficient diet has not been proven to contribute to osteoporosis.
A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?
Initiating weight-bearing exercise routines Explanation: Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg
A 42-year-old man has a recent amputation of the left leg below the knee as a result of a heavy farm machinery accident. Which intervention should the nurse include in the plan of care for this patient?
Lay prone with hip extended for 30 minutes four times per day. To prevent hip flexion contractures, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.
A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury?
Maintain a patent airway. Explanation: Initial care is focused on establishing and maintaining a patent airway and supporting ventilation. Innervation to the intercostal muscles is affected; if spinal edema extends to the C4 level, paralysis of the diaphragm usually occurs. The effects and extent of edema are unpredictable in the first hours, and respiratory status must be closely monitored. Suction equipment should be readily available. Monitoring vital signs, maintaining proper alignment, and turning and positioning are important, but the priority nursing intervention is maintaining a patent airway.
A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?
Maintain two to three finger widths between the axillary fold and underarm piece grip. Explanation: The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.
The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system?
Muscle strength is scale grade 3/5 Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.
The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg?
Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs.
A client is brought to the emergency department after injuring his right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?
One side of the bone is broken and the other side is bent. Explanation: In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.
Which goal is the priority for a client with a fractured femur who is in traction at this time?
Prevent effects of immobility while in traction. Explanation: The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-motion exercises for the joints that are not immobilized. Although not the priority, the nurse also should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis should be placed on what the client can do, such as participating in daily care and exercises to maintain muscle strength. Finding diversional activities is not a priority at this moment. Although the client must adapt to the inactivity, helping the client develop coping skills is the priority at this time.
When caring for a client with acute osteomyelitis in the right tibia, which measure is most appropriate to implement when repositioning the client's leg?
Support the leg above and below the affected area when positioning. Explanation: Acute osteomyelitis can be very painful. Therefore, the extremity must be handled carefully and moved slowly. The most appropriate action when moving an extremity with acute osteomyelitis is to ensure that the extremity is carefully supported above and below the affected area. A splint may be useful to decrease discomfort. Holding the leg by the ankle or allowing the client to move the leg is inappropriate because doing so does not provide adequate support to the affected area. Applying warm, moist compresses does not decrease the need to adequately support the affected area.
A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information?
The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action?
Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?
a 74-year-old who has periodontal disease with periodontitis Explanation: Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, or elderly, and those who have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.
The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse?
ataxic gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority.
When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints (select all that apply)?
hinge joint of the knee; Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.
The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?
hypovolemic Explanation: A fractured femur, especially an open fracture, can cause much soft tissue damage and lead to significant blood loss. Hypovolemic shock can develop. Cardiogenic shock occurs when cardiac output is decreased as a result of ineffective pumping. Neurogenic shock occurs as a result of an impaired autonomic nervous system function. Anaphylactic shock is the result of an allergic reaction.
A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include:
inability to perform active movement and pain with passive movement. Explanation: With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement.
A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:
increase the client's fluid intake to 3,000 mL/day. Explanation: The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool. A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool. Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement. While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.
A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of:
organ meats Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis
A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of:
organ meats. Explanation: Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which finding indicates a complication?
pin moves slightly at insertion site Explanation: Skeletal pins should not be loose and able to move. Any pin loosening should be reported immediately. Slight serous drainage is normal and may crust around the insertion site or be present on the dressing. The pin insertion site should be cleaned with aseptic technique according to facility policy. Pin insertion sites are typically not painful; pain may be indicative of an infection and should be reported.
A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to:
realign fracture fragments. t Explanation: Traction promotes realignment of the bone fragments. This will facilitate subsequent internal fixation. Traction immobilizes the fracture site and may increase the client's comfort. Mobilization could result in further damage. The use of traction does not prevent neurologic damage and can, in fact, cause pressure that leads to nerve damage. Traction increases circulation to the affected part but does not control internal bleeding. Traction may create, rather than prevent, a problem with skin integrity.
Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches?
squeezing a rubber ball Explanation: A client being prepared for crutch walking should be taught to support weight with the hands when crutch walking. Supporting weight in the axillae is contraindicated owing to the risk of possible nerve damage and circulatory obstruction. The client should be taught to squeeze a ball vigorously to help strengthen the hands in preparation for weight bearing with the hands. Hair combing is not likely to strengthen the hands. Wrist flexion and extension may help with wrist joint mobility but will not strengthen the hands. Using the hands to push into the mattress will not be helpful because the mattress will not provide sufficient resistance to strengthen the hands.
The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:
strengthen the muscles while keeping the joints stationary. Explanation: An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process. Isometric exercise do not require specialized equipment, but this does not explain the benefits of the exercises. Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them. Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness.
The client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. The nurse should assess the client for:
tinnitus. Explanation: Tinnitus (ringing in the ears) is a common symptom of aspirin toxicity. Dysuria, chest pain, and drowsiness are not associated with aspirin toxicity.
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?
Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.
The nurse should instruct a family living in a rural area where the drinking water is not fluoridated to use which dietary means of obtaining a significant amount of fluoride?
tea Explanation: Most foods—including yogurt, citrus juices, and natural cheeses—contain limited amounts of fluoride. However, tea contains a significant amount of fluoride and would be the most appropriate suggestion.
The nurse is caring for an older adult male who had open reduction internal fixation (ORIF) of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab results. The nurse should report which lab results to the health care provider (HCP)?
troponin: 1.4 mcg/L (1.4 ?g/L) Explanation: Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level of 1.4 means there has likely been some damage to the heart muscle. Though serum glucose (normal 60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and ESR (normal is less than 20 for males greater than 50 years old) are slightly elevated, this could be explained by normal stress and inflammatory response to surgery. The hematocrit is low (normal 40% to 45% [0.4 to 0.5] for men) but also not unexpected for a client following surgery.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying:
"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." Explanation: Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.
The nurse has instructed the client about the correct positioning of the leg and hip following hip replacement surgery. Which statement indicates that the client has understood these instructions?
"I should avoid bending over to tie my shoes." Explanation: Acute flexion and adduction of the hip should be avoided after hip replacement surgery and the client should not bend over to tie the shoes. Slip on shoes that can be positioned with a long handled shoe horn are preferred. The client may not cross (adduct) the legs as this is a risk for dislocating the prosthesis. The client should not sit in low chairs that will require excessive hip flexion to get in or out of. Hip flexion also increases the risk of dislocation. Frequent walks are encouraged to increase muscle strength and provide hip exercises.
A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching?
"I should use my heating pad this evening to reduce some of the pain in my knee." Explanation: The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.
After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching?
"I should wear a thin cotton undershirt under the brace." The client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, that could lead to skin irritation and breakdown. Applying lotion is not recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow). Applying extra padding (e.g., to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder and lotion is not recommended, because they can cause irritation and skin breakdown.
A client with osteoarthritis tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer?
"Pace yourself and rest frequently, especially after activities." Explanation: A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace herself during daily activities. Telling the client to do her chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace herself and take frequent rests rather than doing all chores at once.
The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?
60, high risk Explanation: Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safet
A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem?
Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.
A nurse is caring for a client who had hip pinning surgery 6 hours ago to treat intertrochanteric fracture of the right hip. What assessment finding requires further investigation by the nurse?
Client is anxious and confused Explanation: The client is anxious and confused is the appropriate answer. Postoperative complications of hip fractures include hemorrhage, pulmonary emboli, and fat emboli. Anxiety and confusion may be indicative of hypoxia as a result of any of above these complications and needs further investigation. Capillary refill of 2-3 seconds is an expected finding, edema is present from both the injury and the surgical intervention. 100 milliliters of bright red drainage 6 hours after surgery should be watched, but is not of immediate concern
When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?
Impaired skin integrity Explanation: Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:
advance both crutches. Explanation: The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.
A 28-year-old woman with a fracture of the proximal left tibia in a long leg cast complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which action should the nurse take?
Notify the health care provider immediately. Clinical manifestations of compartment syndrome include (1) paresthesia, (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment, (3) pressure increases in the compartment, (4) pallor, coolness, and loss of normal color of the extremity, (5) paralysis or loss of function, and (6) pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient's changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.
In reviewing bone remodeling, what should the nurse know about the involvement of bone cells?
Osteoblasts deposit new bone Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.
Which cells are involved in bone resorption?
Osteoclasts Explanation: Osteoclasts carry out bone resorption by removing unwanted bone while new bone is forming in other areas. Chondrocytes are responsible for forming new cartilage. Osteoblasts are bone-forming cells that secrete collagen and other substances. Osteocytes, derived from osteoblasts, are the chief cells in bone tissue
A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk?
Pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?
Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.
To prevent back injury, the nurse should instruct the client to:
avoid prolonged sitting and standing. Explanation: Prolonged sitting and standing should be avoided because they strain the lower back. Pushing objects rather than pulling them will help decrease back strain. Clients should select a semi-firm to firm mattress to provide back support. When sitting, the client should choose a chair with good support and a straight back. The client should sit with feet flat on the floor.
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room?
Send the client on the bed with extra help to stabilize the traction. Explanation: The nurse should send the client to the operating room on the bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
Severe lower back pain Explanation: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms
A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure?
This procedure will not cause any pain or discomfort Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.
A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment should alert the nurse to the development of a possible complication?
clear yellowish fluid on the dressing Explanation: Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The client should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the body's defense mechanism to help clear the lungs of the anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a respiratory infection
A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply.
• The client experiences stiff, swollen joints bilaterally. • Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. • Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators. Explanation: RA is a chronic disorder where individuals experience stiff, swollen joints due to a severe inflammatory reaction. Elevated ESR and x-ray evidence of bony destruction are indicative of severe involvement. RA starts insidiously, with fatigue, persistent low-grade fever, anorexia, and vague skeletal symptoms, usually in middle age between the ages 35 and 50 years. Maintaining the ROM by a prescribed exercise program is essential, but clients must rest between activities. Salicylates and nonsteroidal anti-inflammatory drugs are considered the first-line treatments
During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question
During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height." Explanation: The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height. This client's history doesn't indicate spinal compression. Telling the client that measuring tools used to obtain the client's height may have a discrepancy or that the posture begins to stoop after middle age doesn't address the client's question.
A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. She asks which of the tests ordered will determine if she is positive for the disorder. Which statement by the nurse is most accurate?
"The diagnosis won't be based on the findings of a single test but by combining all data found." Explanation: There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express her feelings about the potential diagnosis don't answer the client's question
"I don't know if I'll be able to get off that low toilet seat at home by myself." Explanation: The client requires additonal teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching?
The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?
A diet high in protein and nutrients Explanation: It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bedrest is not common in care and assistive devices are used only in the acute period
The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?
A diet high in protein and nutrients Explanation: It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bedrest is not common in care and assistive devices are used only in the acute period.
What are important nursing priorities on the first postoperative day for a client who has had an open reduction and internal fixation (ORIF) after a right hip fracture?
Assessing the neurovascular status in the right leg, providing pain control, encouraging position changes, and early ambulation Explanation: Assessing the neurovascular status, including circulation and innervation, is very important postoperatively. Control of pain is also a priority. Maintaining the integrity of the skin through frequent turns and ambulation will prevent pressure ulcers. Correct postoperative positioning involves maintaining the leg in a neutral position and preventing adduction. Bed rest can result in immobility consequences. Assessing skin integrity and nutritional status is positive, but maintaining bedrest is incorrect. Reorienting frequently will not prevent disorientation, and the nurse would not restrict pain measures.
A 50-year-old patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem?
Bursitis Bursitis is common in adults over age 40 and with repetitive motion, such as raking. Plantar fasciitis frequently occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone, not the shoulder, and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not repetitive motion.
A 19-year-old male patient has a plaster cast applied to the right upper extremity for a Colles' fracture after a skateboarding accident. Which action, if taken by the nurse, is the most appropriate?
Elevate the right arm on two pillows for 24 hours.Elevate the right arm on two pillows for 24 hours. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. The casted extremity should be elevated at or above the heart level to reduce swelling or inflammation. Ice should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry but the patient should perform active movements of the shoulder to prevent stiffness or contracture.
The home care nurse visits a 74-year-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse?
Left leg externally rotated and shorter than the right leg Clinical manifestations of a hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain
Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?
Risk for injury related to altered mobility Explanation: Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, Risk for injury is the most appropriate nursing diagnosis. Impaired urinary elimination, Ineffective breathing patterns, and Imbalanced nutrition: Less than body requirements are incorrect because osteoarthritis doesn't affect urinary elimination, breathing, or nutrition
A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?
Teach the client how to prevent problems caused by immobility. Explanation: By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.
A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes previously. Which area should be the nurse's next assessment?
distal pulse Explanation: The nurse should assess the client's ability to move the toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's comments suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.
The nurse is planning an educational program about the prevention of osteoporosis for a group of women. Which preventive measures would be appropriate for the nurse to include in the teaching plan?
encouraging weight-bearing exercise on a regular basis Explanation: Exercise, especially weight-bearing exercise such as walking or jogging, is recommended on a regular basis to maintain high-density bone mass. Diet should be high in calcium and vitamin D; increasing the daily intake of protein is not appropriate. It is recommended that premenopausal women consume about 1,000 to 1,200 mg of calcium daily. Sunbathing is not recommended.
Two days after being placed in a cast for a fractured femur, the client suddenly has chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for:
fat embolism syndrome. Explanation: Clients with fractures of the long bones such as the femur are particularly susceptible to fat embolism syndrome (FES). Signs and symptoms include chest pain, dyspnea, tachycardia, and cyanosis. Changes in mental status are caused by hypoxemia and can be the first symptoms noted in FES. The client can also be restless and febrile and can develop petechiae. Osteomyelitis is infection of the bone; signs and symptoms of osteomyelitis do not include respiratory symptoms. Compartment syndrome causes signs of localized neurovascular impairment, not systemic symptoms. Venous thrombosis occurs in the lower extremities and is caused by venous stasis.
Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?
free, easy movement of the joints Explanation: ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Footdrop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.
After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client:
has experienced a dislocation of the hip prosthesis. Explanation: Classic signs of dislocation of the hip prosthesis include increasing pain, abnormal rotation, shortened leg, difficulty or inability moving the leg, and misalignment of the leg. The nurse should notify the surgeon so that the prosthesis can be repositioned. Muscle spasm will cause pain but would not be responsible for the internal rotation and shortening of the extremity. Repositioning the client will not help this situation. The surgeon will have to relocate the hip joint. Muscle-strengthening exercises may help prevent subsequent dislocations; however, hip precautions must be maintained until complete healing has occurred.
To protect a client's skin under a back brace, the nurse should:
have the client wear a thin cotton shirt under the back brace. Explanation: Having the client wear a thin cotton shirt that is close fitting to avoid having extra folds that could cause pressure under a back brace helps to protect the skin and to keep the brace free of skin oils and perspiration. Using padding may increase pressure points. Lubricating or powdering the skin under the back brace will not provide protection from irritation by the brace.
A 30-year-old client hospitalized with a fractured femur, which is being treated with skeletal traction, has not had a bowel movement for 2 days. The nurse should:
increase the client's fluid intake to 3,000 mL/day. Explanation: Increasing the client's fluid intake to 3,000 mL/day, unless contraindicated, is the most appropriate action. Typically, clients who are immobilized by skeletal traction are given stool softeners. Treating constipation with diet, increased fluids, and stool softeners is preferred to the administration of an enema. Placing the client on the bedpan will not encourage a bowel movement. Range-of-motion movements maintain joint mobility but do not stimulate peristalsis
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?
ineffective coughing and deep breathing Explanation: In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention
A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:
initiate a time-out. Explanation: The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedure verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertis
The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which outcome indicates the goals of therapy have been met?
joint range of motion improved Explanation: One outcome criterion for the client with osteoarthritis is improved joint mobility. It is probably not possible to arrest the disease. Gold compound is administered to clients with rheumatoid arthritis, not osteoarthritis. Outcome criteria should be specific; feeling better is too general to be useful.
Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
local joint pain Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain. Rheumatoid arthritis has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweigh
The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first:
mark the area of drainage. The nurse should mark the bloody drainage and observe it again in 10 minutes to assess if the bleeding is continuing. There is no need to notify the health care provider immediately because some oozing and bloody drainage are expected. A fresh postoperative dressing should not be changed unless the health care provider prescribes it. Although the wound edges will be closed, no epithelialization has occurred yet to protect the deep tissues. Undressing the wound at this point increases the risk of a wound infection. Given the slight amount of drainage, there is no need to reinforce the dressing.
After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching?
sweeping the front porch Explanation: Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to:
take NSAIDs with food. Explanation: NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs
A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, the nurse should first:
teach the client how to do isometric exercise of the quadriceps. Explanation: The nurse should teach the client how to do isometric exercise, contraction of the quadriceps muscle without movement of joint, to maintain muscle strength. Physical therapy may assist the client later, and will then teach the client how to do active exercises and crutch walking if prescribed. The client will be able to move the unaffected limb; the family will not need to assist. If the client will be using crutches, building upper extremity strength will be helpful, but the immediate need is to maintain and develop strength in the quadriceps
To prevent external rotation of the client's hips while lying on the back, it would be best for the nurse to place:
trochanter rolls alongside the legs from ilium to midthigh. Explanation: Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips. Pillows can be used only as a temporary measure because they cannot hold the legs and hips in proper alignment over a prolonged period. Placing sandbags from the knees to the ankle will not effectively support the hips in proper alignment. A footboard does not help to keep the legs and hips in proper alignment.
The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Which information is not necessary to obtain every 15 minutes during the first postoperative hour?
urine output Explanation: The urine output does not have to be checked every 15 minutes for a client who has had an arthroscopy because this client probably does not have a catheter in place. If the client voids, the output would be recorded. Assessments every 15 minutes during the first hour would include vital signs, pulse oximeter values, and pain to monitor the client's comfort level and check for compartment syndrome. Neurovascular checks distal to the operative site are especially vital because a tourniquet was used proximal to the operative site during the surgical procedure and because edema may develop during the postoperative period.
A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should:
use only the palms of the hand when handling the cast. Explanation: The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are rough and are causing irritation to the client's skin. The nurse should not keep the child in the same position until the cast is dry. Doing so would prohibit proper toileting and elimination and would produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a health care provider (HCP) is not necessary in this instance. If needed, a fan can be used to circulate the room air.
The client with an above-the-knee amputation is to be fitted with a functioning prosthesis. The nurse has been teaching the client how to care for the residual limb. Which behavior would demonstrate that the client has an understanding of proper residual limb care? The client:
washes and dries the residual limb daily. Washing and thoroughly drying the residual limb daily are important hygiene measures to prevent infection. Nothing should be applied to the residual limb after it is cleansed. Powder may cause excessive drying and cracking of the skin, and cream may soften the skin excessively. The residual limb should be inspected daily with a mirror for early signs of skin breakdown. To reduce residual limb swelling, the prosthesis should be removed only at night.
Following a client's total hip replacement, what should the nurse do? Select all that apply.
• Encourage the client to use the overhead trapeze to assist with position changes. • Use a fracture bedpan when needed by the client. • When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Explanation: Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement