Ch 41 NCLEX
Which actions by the nurse demonstrate an understanding of caring for a patient in traction? Select all that apply. a) Ensuring that the weights are hanging freely b) Assessing pain level frequently c) Placing a trapeze on the bed d) Removing skeletal traction to turn and reposition the patient e) Assessing patient's alignment in the bed
a) Ensuring that the weights are hanging freely, b) Assessing pain level frequently, c) Placing a trapeze on the bed, e) Assessing patient's alignment in the bed Explanation: The weights must hang freely with the patient in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The patient will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.
The patient is scheduled for a meniscectomy of the right knee. The nurse would plan postoperative care based on what surgical procedure? a) Incision and diversion of the muscle fascia b) Replacement of one of the articular surfaces of a joint c) Replacement of knee with artificial joint d) Excision of damaged joint fibrocartilage
d) Excision of damaged joint fibrocartilage Explanation: The most common site for meniscectomy is the knee; the procedure refers to the excision of damaged joint fibrocartilage. Fasciotomy refers to the incision and diversion of the muscle fascia to relieve muscle constriction. Hemiarthroplasty refers to the replacement of one of the articular surfaces of a joint. Total joint arthroscopy is the replacement of a joint with synthetic material.
A patient with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which of the following is the priority action by the nurse? a) Assess for complications. b) Assess for previous opioid drug use. c) Reposition the patient for comfort. d) Teach relaxation techniques.
a) Assess for complications. Explanation: Unrelieved pain can be an indicator of a complication, such as, compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the patient for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.
A patient with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? a) Notify the physician. b) Document the findings. c) Assess patient's hemoglobin and hematocrit. d) Prepare for surgical removal of the fixator.
b) Document the findings. Explanation: Serous drainage and redness at the pin site is an expected finding for 24-48 hours postinsertion. The nurse should document the findings and continue to monitor the site. The physician does not need to be notified unless other signs and symptoms are present. The fixator does not need to be removed at this time. The greatest concern is for infection; assessing the hemoglobin and hematocrit are not relevant to assessing for infection.
The nurse teaches the patient which of the following interventions in order to avoid hip dislocation after replacement surgery? a) Never cross the affected leg when seated. b) Bend forward only when seated in a chair. c) Avoid placing a pillow between the legs when sleeping. d) Keep the knees together at all times.
a) Never cross the affected leg when seated. Explanation: Crossing the affected leg may result in dislocation of the hip joint after total hip replacement. The patient should be taught to keep the knees apart at all times. The patient should be taught to put a pillow between the legs when sleeping. The patient should be taught to avoid bending forward when seated in a chair.
Which of the following orthopedic surgeries is done to correct and align a fracture after surgical dissection and exposure of the fracture? a) Joint arthroplasty b) Open reduction c) Total joint arthroplasty d) Arthrodesis
b) Open reduction Explanation: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.
Which of the following principles apply to the patient in traction? a) Weights should rest on the bed. b) Skeletal traction is never interrupted. c) Weights are removed routinely. d) Knots in the ropes should touch the pulley.
b) Skeletal traction is never interrupted. Explanation: Skeletal traction is applied directly to the bone and is never interrupted. In order to be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.
Which device is designed specifically to support and immobilize a body part in a desired position? a) Brace b) Traction c) Sling d) Splint
d) Splint Explanation: A splint may be applied to a fractured extremity initially until swelling subsides. A brace is an externally applied device to support a body part, control movement, and prevent injury. A sling is used to support an arm and traction is the use of a pulling force on a body part.
A patient is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm? a) Abduction and adduction of the shoulder b) Repositioning the arm in the cast c) Proper use of a sling d) Use of isometric exercises
d) Use of isometric exercises Explanation: Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the patient is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The patient should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.
Which type of cast encloses the trunk and a lower extremity? a) Hip spica b) Body cast c) Short-leg d) Long-leg
a) Hip spica Explanation: A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.
Which of the following is a benefit of a continuous passive motion (CPM) device when applied after knee surgery? a) It promotes healing by immobilizing the knee joint. b) It provides active range of motion. c) It prevents infection and controls edema and bleeding. d) It promotes healing by increasing circulation and movement of the knee joint.
d) It promotes healing by increasing circulation and movement of the knee joint. Explanation: A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.
Which of the following is the most effective cleansing solution to complete pin site care? a) Betadine b) Chlorhexidine c) Hydrogen peroxide d) Alcohol
b) Chlorhexidine Explanation: Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and Betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually damage healthy tissue.
Which would be consistent as a component of self-care activities for the patient with a cast? a) Cover the cast with plastic to insulate it. b) Cushioning rough edges of the cast with tape c) Use plastic hanger wrapped in gauze to scratch under the cast. d) Place the casted extremity in a dependent position frequently.
b) Cushioning rough edges of the cast with tape Explanation: The patient can cushion rough edges with tape to prevent skin irritation. The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The casted extremity is to be elevated to heart level frequently; a dependent position will increase swelling. A patient should not use any object to scratch under the cast.
Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery? a) Instructing about using patient-controlled analgesia, if prescribed b) Instructing about exercise, as prescribed c) Applying cold packs d) Applying antiembolism stockings
d) Applying antiembolism stockings Explanation: Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a patient who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain while ROM exercises help in maintaining muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling and this does not prevent deep vein thrombosis.
A patient diagnosed with a right ulnar fracture asks why the cast needs to go all the way up the arm. What is the best response by the nurse? a) "This will allow for the strength in the arm to remain consistent." b) "The method will allow for the fastest healing time and the greatest mobility." c) "When a spica cast is ordered, the arm must be immobilized." d) "The joint above the fracture and below the fracture must be immobilized."
d) "The joint above the fracture and below the fracture must be immobilized." Explanation: Generally, the joints proximal and distal to the fracture are immobilized to promote healing. The purpose is not for the strength to remain consistent, most patients will lose strength. A spica cast would not be ordered for an ulnar fracture. Although immobilizing the joints above and below fractures may aide in healing time, it does not allow for increased mobility.
A patient is placed in traction for a femur facture. The nurse would document what as the expected outcomes of traction? Select all that apply. a) Minimization of muscle spasms b) Increased ability to bear weight c) Full range of motion to extremity d) Reduction of deformity e) Decreased pedal pulse f) Realignment of a fracture
a) Minimization of muscle spasms, d) Reduction of deformity, f) Realignment of a fracture Explanation: Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity. Traction does not allow for full range of motion or an increased ability to bear weight. The patient is confined to the bed while in traction. A decreased pulse is a sign of circulatory compromise and should be investigated and reported.
Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure? a) Arthroplasty b) Arthrodesis c) Osteotomy d) Fasciotomy
d) Fasciotomy Explanation: A fasciotomy is a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure. An osteotomy is a surgical cutting of bone. An arthroplasty is a surgical repair of a joint. Arthrodesis is a surgical fusion of a joint.
What is the best action by the nurse to achieve the optimal outcomes when caring for a patient with a musculoskeletal disorder that is using a cast? a) Educating the patient on cast care and complications b) Preparing the patient for cast application c) Providing effective pain control d) Assessing for neurovascular compromise
a) Educating the patient on cast care and complications Explanation: Educating the patient is essential to achieve optimal outcomes. Although the nurse should prepare the patient for cast applications, assess for neurovascular compromise, and provide effective pain control, these interventions are centered on the care provided by the nurse. The patient is more likely to be in the home setting while a cast is in place, requiring the patient to have the education to properly care for the cast and have the knowledge of the complications so that early interventions can happen.
A patient with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. a) Provide support to the injured extremity. b) Apply ice to extremity. c) Prepare for cast removal. d) Elevate the arm above the heart. e) Assess neurovascular status every 8 hours.
a) Provide support to the injured extremity., c) Prepare for cast removal. Explanation: The nurse should anticipate immediate removal of the cast and provide support to the injured extremity. Neurovascular status should be assessed more frequently than every 8 hours. If the patient is not showing improvement in the neurovascular status, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above. Ice should not be used as it could further decrease blood flow to the extremity.
Which of the following statements is accurate regarding care of a plaster cast? a) The cast will dry in about 12 hours. b) The cast must be covered with a blanket to keep it moist during the first 24 hours. c) The cast can be dented while it is damp. d) A dry plaster cast is dull and gray.
c) The cast can be dented while it is damp. Explanation: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.
A patient in the emergency department is being treated for a wrist fracture. The patient asks why a splint is being applied instead of a cast. What is the best response by the nurse? a) "Not all fractures require a cast." b) "A splint is applied when more swelling is expected at the site of injury." c) "You would have to stay here much longer because it takes a cast longer to dry." d) "It is best if an orthopedic doctor applies the cast."
b) "A splint is applied when more swelling is expected at the site of injury." Explanation: Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will experience swelling as part of the inflammation process. The patient would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.
Which interventions should a nurse implement as part of initial pain relief measure for the patient with a cast? Select all that apply. a) Application of a new cast b) Elevation of the involved part c) Administration of analgesics d) Provide passive range-of-motion e) Application of cold packs
b) Elevation of the involved part, c) Administration of analgesics, e) Application of cold packs Explanation: Most pain can be relieved by elevating the casted part of the body, and by applying cold packs as prescribed and administering analgesics. The application of a new cast and providing passive range-of-motion would not assist in decreasing initial pain for a patient with a cast.
An unresponsive patient had a plaster cast applied 8 hours ago to the right lower leg. When moving the patient, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? a) Remove the cast immediately. b) Notify the physician. c) Assess for pedal pulse and mobility of toes. d) Document the findings.
b) Notify the physician. Explanation: Indentations in the cast can cause skin irritations and breakdown. The physician needs to be notified to assess the need for a new cast or manipulation of the current cast to prevent the skin breakdown. The nurse will need to document the findings and actions taken to resolve the issue but cannot document actions without completing an action, such as notifying the physician. The cast does not need immediate removal. Pedal pulse will indicate if a circulatory issue is present but with the patient being unresponsive, mobility of the toes cannot be assessed.
The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Cover the cast with plastic or rubber b) Keep the cast below heart level c) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems d) Fix a broken cast by applying tape
c) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems Explanation: Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems, and do not cover it with plastic or rubber. A cast should be kept dry but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. A casted extremity should be elevated frequently to heart level to prevent swelling. A broken cast should be reported to the physician and the patient should not attempt to fix it.
A patient with a fractured ankle is having a fiberglass cast applied. The patient starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate? a) Call for assistance to hold the patient is the required position until the cast has dried. b) Administer antianxiety and pain medication. c) Explain that the sensation being felt is normal and will not cause burns to the patient. d) Remove the cast immediately, notifying the physician.
c) Explain that the sensation being felt is normal and will not cause burns to the patient. Explanation: A fiberglass cast when applied will give off heat. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not cause burns to the skin. By explaining these principles to the patient, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the patient may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.
