Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Delegate the transfer to nursing assistive personnel (NAP). d. Decrease the pain medication before getting the patient up.

ANS: A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer. DIF: Cognitive Level: Apply (application) REF: 1477 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. b. Assess for contractures. c. Check peripheral pulses. d. Monitor for hip dislocation.

ANS: A Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction. DIF: Cognitive Level: Apply (application) REF: 1482 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use. DIF: Cognitive Level: Apply (application) REF: 1476 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The occupational health nurse will teach the patient whose job involves many hours of typing to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

ANS: A Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling. DIF: Cognitive Level: Apply (application) REF: 1465 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

ANS: A Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members. DIF: Cognitive Level: Apply (application) REF: 1471 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. assess the surgical site for hemorrhage. b. remove the prosthesis and wrap the site. c. place the patient in a side-lying position. d. keep the residual limb elevated on a pillow.

ANS: A The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture. DIF: Cognitive Level: Apply (application) REF: 1488 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion. DIF: Cognitive Level: Apply (application) REF: 1479 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take? a. Explain the reasons for the pain. b. Administer prescribed analgesics. c. Reposition the patient to assure good alignment. d. Inform the patient that this pain will diminish over time.

ANS: B Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment. DIF: Cognitive Level: Analyze (analysis) REF: 1488 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management.

ANS: B A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain management. DIF: Cognitive Level: Apply (application) REF: 1467 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

ANS: B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position. DIF: Cognitive Level: Apply (application) REF: 1473 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing. DIF: Cognitive Level: Apply (application) REF: 1477 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention. DIF: Cognitive Level: Apply (application) REF: 1485 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first? a. Send the patient for ankle x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

ANS: B Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied. DIF: Cognitive Level: Analyze (analysis) REF: 1464 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull on shoes and socks. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient. DIF: Cognitive Level: Apply (application) REF: 1483 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

ANS: B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. DIF: Cognitive Level: Apply (application) REF: 1484 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will begin work with a physical therapist tomorrow." c. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." d. "The surgeon will use the drop-arm test to determine the success of surgery."

ANS: B Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop-arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation. DIF: Cognitive Level: Apply (application) REF: 1467 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.

ANS: B The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury. DIF: Cognitive Level: Apply (application) REF: 1481 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

ANS: B The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw. DIF: Cognitive Level: Apply (application) REF: 1486 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

ANS: B The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture. DIF: Cognitive Level: Apply (application) REF: 1489 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? a. Observe output from the surgical drain. b. Administer prescribed pain medication. c. Instruct the patient about benefits of early ambulation. d. Change the dressing and document the wound appearance.

ANS: B The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation. DIF: Cognitive Level: Analyze (analysis) REF: 1491 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism. DIF: Cognitive Level: Analyze (analysis) REF: 1480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

ANS: B UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application) REF: 1471 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying. DIF: Cognitive Level: Apply (application) REF: 1472 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function. DIF: Cognitive Level: Analyze (analysis) REF: 1465 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries. DIF: Cognitive Level: Apply (application) REF: 1463 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury. DIF: Cognitive Level: Apply (application) REF: 1472 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast. DIF: Cognitive Level: Apply (application) REF: 1477 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

ANS: C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture. DIF: Cognitive Level: Apply (application) REF: 1475 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury. DIF: Cognitive Level: Analyze (analysis) REF: 1486 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture. DIF: Cognitive Level: Analyze (analysis) REF: 1464 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side. DIF: Cognitive Level: Apply (application) REF: 1481 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.

ANS: C The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned. DIF: Cognitive Level: Analyze (analysis) REF: 1465 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery. DIF: Cognitive Level: Apply (application) REF: 1491 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment. DIF: Cognitive Level: Analyze (analysis) REF: 1464 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. assess the pedal pulses. d. verify tetanus immunization.

ANS: C The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound. DIF: Cognitive Level: Analyze (analysis) REF: 1464 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

ANS: C The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion about the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state. DIF: Cognitive Level: Analyze (analysis) REF: 1487 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

ANS: D Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported. DIF: Cognitive Level: Analyze (analysis) REF: 1480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. have the patient lift the buttocks slightly by using a trapeze over the bed. d. turn the patient partially to each side with the assistance of another nurse.

ANS: C The patient can lift the buttocks slightly off the bed by using a trapeze. This will not affect the fracture fragments on the right leg. Turning the patient will tend to move the fracture fragments, causing pain and possible nerve impingement. Disconnecting the traction will interrupt the weight needed to decrease muscle spasms. DIF: Cognitive Level: Apply (application) REF: 1481 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the O2 saturation. d. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation. DIF: Cognitive Level: Analyze (analysis) REF: 1480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions. DIF: Cognitive Level: Analyze (analysis) REF: 1464 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the other problems caused by immobility are not as likely. DIF: Cognitive Level: Apply (application) REF: 1478 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis MSC: NCLEX: Physiological Integrity

Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

ANS: D After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Surgeon orders allow weight bearing as tolerated after this procedure; protected weight bearing is not needed. DIF: Cognitive Level: Apply (application) REF: 1491 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

ANS: D Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention. DIF: Cognitive Level: Analyze (analysis) REF: 1479 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. burning in the right elbow and forearm. c. tremor when gripping with the right hand. d. tingling in the right thumb and index finger.

ANS: D Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome. DIF: Cognitive Level: Understand (comprehension) REF: 1466 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching. DIF: Cognitive Level: Apply (application) REF: 1483 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

ANS: D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain. DIF: Cognitive Level: Apply (application) REF: 1465 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

ANS: C Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation. DIF: Cognitive Level: Analyze (analysis) REF: 1480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.