exam 5
When assessing the body functions of a patient with increased ICP, what shouldthe nurse assess first? A) Circulatory and respiratory status B) Extremity strength testing C) Corneal reflex testing D) Urinary output
A
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A) Ataxia and confusion B) Sodium depletion C) Tonic-clonic seizure D) Urinary incontinence
A A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia.
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A) Hemorrhagic skin rash B) Edema C) Cyanosis D) Dyspnea on exertion
A
A patient with an open fracture of the left tibia and soft tissue damage underwent a surgical reduction and fixation of the tibia with debridement of nonviable tissue and drain placement. When assessing the patient during the postoperative period, the nurse will be most concerned about a. fever with chills and night sweats. b. light yellow drainage from the wound. c. pain on movement of the affected limb. d. muscle spasms around the affected bone.
A Rationale: Fever, chills, and night sweats are suggestive of osteomyelitis. The other clinical manifestations are typical after a fracture repair.
A patient has chronic osteomyelitis of the left femur, which is being managed at home with self-administration of IV antibiotics. On a home visit, the nurse identifies the nursing diagnosis of ineffective therapeutic regimen management when the nurse finds that the patient a. is unable to plantar-flex the foot on the affected side. b. uses crutches to avoid weight bearing on the affected leg. c. takes and records the oral temperature twice a day. d. is irritable and frustrated with the length of treatment required.
A Rationale: Footdrop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective management of the osteomyelitis.
The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity what actions should the nurse take? select all that apply: A) loosen restrictive clothing B) Turn patient to the side C) protect the patient's head from injury D) place a padded tongue blade between the patients teeth E) restrain the patients extremities to prevent soft tissue and bone injury
A, B, C
A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest
ANS: A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running .c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood .e. Transfuse each unit over 8 hours.
ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted.
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time
ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility.
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.) a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix) d. Lepirudin (Refludan) e. Methylprednisolone (Solu-Medrol)
ANS: A, B, D The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. The other drugs are not used. Clopidogrel is an antiplatelet agent used to reduce the likelihood of stroke or myocardial infarction. Methylprednisolone is a steroid used to reduce inflammation.
A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.
ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.
A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion
ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.
Which of these prescribed interventions will the nurse implement first for ahospitalized patient who is experiencing continuous tonic-clonic seizures? A) Give phenytoin (Dilantin) 100 mg IV. B) Monitor level of consciousness (LOC). C) Obtain computed tomography (CT) scan. D) Administer lorazepam (Ativan) 4 mg IV.
D
A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medrol)
ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem.
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.
ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.
A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)
ANS: C This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition.
A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.
ANS: C, D, E This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.
A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves
ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.
A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon
ANS: D While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply). A Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B Administer phenytoin (Dilantin) 200 mg PO daily. C Teach patient about the need for good oral hygiene. D Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
B
A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is A) administering codeine for relief of head and neck pain. B) controlling fever with prescribed drugs and cooling techniques. C) keeping the room dark and quiet to minimize environmental stimulation. D) maintaining the patient on strict bed rest with the head of the bed slightly elevated.
B
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A) Congenital anatomic abnormality of the meninges B) Lack of acquired resistance to the various etiologic organisms C) Occlusion or narrowing of the CSF pathway D) Natural affinity of the CNS to certain pathogens
B
What are the key manifestations of bacterial meningitis? A) Papilledema and psychomotor seizures B) High fever, nuchal rigidity, and severe headache C) Behavioral changes with memory loss and lethargy D) Jerky eye movements, loss of corneal reflex, and hemiparesis
B
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A) Bladder infection B) Middle ear infection C) Fractured clavicle D) Septic arthritis
B
Which of the following pathologic processes is often associated with aseptic meningitis? A) Ischemic infarction of cerebral tissue B) Childhood diseases of viral causation such as mumps C) Brain abscesses caused by a variety of pyogenic organisms D) Cerebral ventricular irritation from a traumatic brain injury
B
A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin? a. Obtain the patient's oral temperature. b. Review the patient's BUN and creatinine levels. c. Ask the patient about any nausea. d. Change the wet-to-dry dressing.
B Rationale: Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
A patient is hospitalized for initiation of regional antibiotic perfusion for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? a. Frequent weight-bearing exercise b. Immobilization of the right leg c. Avoid administration of NSAIDs d. Support right leg in a flexed position
B Rationale: Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures.
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies
B This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related.
An early sign of increased intracranial pressure that the nurse should assess foris... A) Cushing's triad B) unexpected vomiting C) decreasing level of consciousness D) dilated pupil with sluggish response to light
C
Which patient should the nurse assess first? A) Patient with a skull fracture whose nose is bleeding B) Older patient with a stroke who is confused and whose daughter is present C) Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale D) Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has hadcontinued vomiting
C
An elementary teacher who has just been diagnosed with epilepsy after havinga generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will betoo upsetting if I have a seizure at work. Which response by the nurse is best? A) You may want to contact the Epilepsy Foundation for assistance. B) You might benefit from some psychologic counseling at this time. C) The Department of Vocational Rehabilitation can help with work retraining. D) Most patients with epilepsy are well controlled with antiseizure medications.
D
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? a. The reason for taking oral antibiotics for 7 to 10 days after discharge b. The need for daily aerobic exercise to help maintain muscle strength c. How to monitor and care for the long-term IV catheter site d. How to apply warm packs safely to the leg to reduce pain
C Rationale: The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
A patient has a tonic-clonic seizure while the nurse is in the patients room.Which action should the nurse take? A) Insert an oral airway during the seizure to maintain a patent airway. B) Restrain the patients arms and legs to prevent injury during the seizure. C) Avoid touching the patient to prevent further nervous system stimulation. D) Time and observe and record the details of the seizure and postictal state.
D
A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what? A) Mosquito or tick bites B) Chickenpox C) Cold sores D) An upper respiratory infection
D
A 32-year-old patient who has had an 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. 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 patients blood pressure
a. Notify the health care provider. The patients 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.
In which order will the nurse implement these collaborative interventions prescribed for a patient being admitted who has acute osteomyelitis with a temperature of 101.2 F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Send to radiology for computed tomography (CT) scan of right leg. c. Administer gentamicin (Garamycin) 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.
a. Obtain blood cultures from two sites. c. Administer gentamicin (Garamycin) 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever. b. Send to radiology for computed tomography (CT) scan of right leg. The highest priority for possible osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last.
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. You will need to check and clean the pin insertion sites daily. b. The external fixator can be removed for your bath or shower. c. You will need to remain on bed rest until bone healing is complete. d. Prophylactic antibiotics are used until the external fixator is removed.
a. You will need to check and clean the pin insertion sites daily. Pin insertion sites should be cleaned daily to decrease the 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 when an external fixator is used.
Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis? a. Ask the patient about any nausea. b. Review the patients creatinine level. c. Obtain the patients oral temperature. d. Change the prescribed wet-to-dry dressing.
b. Review the patients creatinine level.Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patients temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
After being hospitalized for 3 days with a right femur fracture, a 32-year-old 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 the prescribed PRN oxygen at 4 L/min. c. Check the patients legs for swelling or tenderness. d. Notify the health care provider about the symptoms.
b. Administer the prescribed PRN oxygen at 4 L/min.
Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a 62-year-old patient who has an intracapsular fracture of the right femur? a. Check peripheral pulses. b. Ask about hip pain level. c. Assess for hip contractures. d. Monitor for hip dislocation.
b. Ask about hip pain level. Bucks 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 Bucks traction.
A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patients weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).
b. Check the postoperative orders for the patients weight-bearing status. 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 this skill.
The nurse notes crackling sounds and a grating sensation with palpation of an older patients elbow. How will this finding be documented? a. Torticollis b. Crepitation c. Subluxation d. Epicondylitis
b. Crepitation Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.
When caring for a patient who is using Bucks traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor the skin under the traction boot for redness. b. Ensure that the weight for the traction is off the floor. c. Check for intact sensation and movement in the affected leg. d. Offer reassurance that hip and leg pain are normal after hip fracture.
b. Ensure that the weight for the traction is off the floor. UAP can be responsible for maintaining the integrity of the traction once it has been established. Assessment of skin integrity and circulation should be done by the registered nurse (RN). UAP should notify the RN if the patient experiences hip and leg pain because pain and effectiveness of pain relief measures should be assessed by the RN.
A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have 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).
b. Wrap the ankle and apply an ice pack. Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. 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.
b. avoid handling the cast using fingertips. 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.
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.
b. for at least 3 weeks. Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.
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 accident? (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.
c. Assess lung sounds. d. Take blood pressure. b. Check pedal pulses. e. Apply splint to the leg. a. Obtain x-rays. f. Administer tetanus prophylaxis. The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status 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-rays. The tetanus prophylaxis is the least urgent of the actions.
A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided 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.
c. Assess the left axilla and change absorbent dressings as needed. 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.
When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Keep the hand immobile to prevent soft tissue swelling. c. Call the health care provider for increased swelling or numbness of the hand. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.
c. Call the health care provider for increased swelling or numbness of the hand. 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 pain after a fracture.
The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the oxygen saturation. d. Observe for facial asymmetry.
c. Check the oxygen saturation. The patients history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange.
Which statement by the patient indicates a good understanding of the nurses teaching about a new short-arm plaster 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.
c. I will apply an ice pack to the cast over the fracture site off and on for 24 hours. 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.
A 42-year-old 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
c. Slow capillary refill of the left foot Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.
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. check the pedal pulses. d. verify tetanus immunizations.
c. check the pedal pulses. The initial nursing action should be assessment of the neurovascular status 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 done if there is an open wound.
Which assessment finding for a patient who has had a surgical reduction of an open fracture of the right radius is most important to report to the health care provider? a. Serous wound drainage b. Right arm muscle spasms c. Right arm pain with movement d. Temperature 101.4 F (38.6 C)
d. Temperature 101.4 F (38.6 C)An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.
After change-of-shift report, which patient should the nurse assess first? a. Patient with a Colles fracture who has right wrist swelling and deformity b. Patient with a intracapsular left hip fracture whose leg is externally rotated c. Patient with a repaired mandibular fracture who is complaining of facial pain d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic
d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic Swelling and bruising after a femoral shaft fracture suggest 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.
A 48-year-old patient with a comminuted fracture of the left femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients 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 patients legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the right leg.
d. have the patient lift the buttocks by bending and pushing with the right leg. The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is 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.
d. risk for infection related to disruption of skin integrity. A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
