Module 12

what are the six P's for compartment syndrome?

1. pain 2. pressure 3. paresthesia (numbness and tingling) 4. pallor 5. paralysis 6. pulsesness

upon waking up in the postanesthesia care unit and seeing a drain with bright red fluid is exiting from his total hip incision, a client asks the nurse, "is this way it's supposed to be?" What should the nurse tell the client? A. "The drainage is blood and fluid that must be drained out for healing" B. "Don't worry about it, ill explain it when you are more awake" C. "This blood is being kept sterile and will be given back to you" D. "ill give you something to make you sleep so you don't worry"

A. "The drainage is blood and fluid that must be drained out for healing"

the client in traction for a fractured femur is having difficulty managing self-care activities. Which outcome indicated a successful completion of a goal of promoting independence for this client? A. The client assists as much as possible in care, demonstrating increased participation over time. B. the client allows the nurse to complete care in an efficient manner without interfering C. the client allows the spouse to assume total responsibility for care D. the client accepts that self-care is not possible while in traction

A. The client assists as much as possible in care, demonstrating increased participation over time.

The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase hip pinning. Which poses the greatest hazard to the client as a risk for falling at home? A. a 4-year-old cocker spaniel B. scatter rugs C. snack tables D. rocking chairs

B. Scatter Rugs

After the application of an arm cast, the client has pain on passive stretching of the fingers, finger swelling and tightness, and loss of function. Based on these data, the nurse anticipates that the client may be developing: A. delayed bone union B. compartment syndrome C. fat embolism D. osteomyelitis

B. compartment syndrome

the client with a fractured tibia has been taking methocarbamol. Which finding indicates that the drug is having the intended effect? A. lack of infection B. reduction in itching C. relief of muscle spams D. rising straight from a chair to standing position

C. relief of muscle spams

the nurse has been assigned to provide care for a group of clients. Each of the clients has been called out to the nurses' station requesting assistance. which client should the nurse see first? A. 32-year-old who has a plaster cast applied to his leg 2 hours ago and reports that the cast feels as if it is getting tighter. B. a 56-year-old male who has an arthroscopy of his left knee 3 hours ago and is asking about being discharged from the hospital today. C. a 60-year-old female who is in traction to manage chronic muscle spasms and is requesting assistance eating her lunch D. a 78-year-old female who had an L-2-L3 laminectomy a day ago and is asking for someone to speak to an upset family member

A. 32-year-old who has a plaster cast applied to his leg 2 hours ago and reports that the cast feels as if it is getting tighter.

The nurse is providing discharge instructions to a client with a leg cast. Which teaching point is most crucial? A. Do not put pressure on the axilla while using crutches B. exercise the joints above and below the cast, as prescribed C. avoid walking on the cast without the healthcare provider's permission D. Report changes in sensation such as numbness or tingling.

D. Report changes in sensation such as numbness or tingling. Teach all of these but D is the mot crucial

to assess the joints, a nurse asks a client to perform various movements. As the client moves their arm away from the midline the nurse evaluates their ability to perform A. protraction B. retraction C. adduction D. abduction

D. abduction

A nurse monitors a client receiving enoxaparin 30 mg subcutaneously BID after hip replacement surgery. Which adverse reaction is the patient most likely to experience? A. anaphylactic shock B. hypersensitivity C. bronchospasm D. bleeding

D. bleeding enoxaparin is an anticoagulant

A client with a hip fracture has undergone surgery for the insertion of a femoral head prosthesis. Which activity should the nurse instruct the client to avoid? A. crossing the legs while sitting down B. sitting on a raised commode seat C. using an abductor splint while laying on the side D. rising straight from a chair to standing position

A. crossing the legs while sitting down This is because it could displace the femoral head

A nurse is caring for a client with a cast on their left arm after sustaining a fracture. Which assessment finding is most significant for this client? A. fingers on the left hand are swollen and cool B. presence of a normal popliteal place C. cast edges are rough, with skin irritation present D. minimal pain in the left arm

A. fingers on the left hand are swollen and cool DO NOT TAKE THE CAST OFF. Call the doc.

the nurse is assessing the neurovascular status of a client's right arm, which has just had a cast applied. The nurse should notify the health care provider when which symptom occurs? A. nail bed capillary refill time of 10 seconds B. localized pain in the right arm C. slight swelling of the fingers D. no pain on passive movement of the fingers.

A. nail bed capillary refill time of 10 seconds

the client has just had a total knee replacement. When assessing the client, which finding should lead the nurse to suspect possible nerve damage? A. numbness B. bleeding C. dislocation D. pinkness

A. numbness

health promotion activities to reduce the incidence of osteoporosis include: A. teaching woman to maintain an adequate calcium intake B. teaching women how to administer pain medication safety C. teaching women to increase caffeine intake as a preventative measure D. teaching women to avoid estrogen replacement therapy when postmenopausal.

A. teaching woman to maintain an adaeuqte calcium intake

after undergoing surgery the previous day for a total knee replacement, a client states not feeling ready to ambulate yet. What should the nurse do? A. Tell the client that they will contact the physician and report the client's noncompliance B. discuss the complications that the client may experience if they don't cooperate with the care plan C. Do nothing because the client has the ultimate right to determine the degree of participation D. document the client's refusal to ambulate.

B. discuss the complications that the client may experience if they don't cooperate with the care plan Complications: clots, infection, artophy, pnemunoia, compartment syndrome, improper healing, VTE

A nurse notices a client lying on the floor at the bottom of the stairs. The clients alert and oriented and state that they fell down several stairs. The client denies pain other than in their arm, which is swollen and appears deformed. After calling for help, what should the nurse do? A. place the client in a sitting position B. immobilize the client arm C. help the clients walk to the nearest nurses station D. raise the client's arm above their heart

B. immobilize the client arm

the second morning after surgery for a below-the-knee amputation of the left leg, the client says, "this sounds crazy, but I feel my left toes tingling." This statement would indicate to the nurse that he is experiencing a A. denial reaction B. phantom-limb-sensation C. hallucination . body image disturbance

B. phantom-limb-sensation

a client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to: A. prevent neurologic damage B. realign fracture fragments C. control internal bleeding D. maintain skin integrity

B. realign fracture fragments. Also used for decreased muscle spasms and decrease pain.

A nurse is caring for a client who recently underwent a total hip replacement. The nurse should: A. east the client onto a low toilet seat. B. allow the client's legs to be crossed at the knees when out of bed. C. use soft chairs when the client is sitting out of bed. D. limit hip flexion of the client's hip when he sits.

D. limit hip flexion of the clients hip when he sits. watch the angle change.

a client in Buck's traction after fracturing the right hip. The nurse should include which action in the care plan? A. removing weight once every shift B. maintaining the bed in the knee-Gatch position C. keeping the client semi-Fowlers position D. maintaining correct body alignment

D. maintaining correct body alignment The reason that we do not put in him knee-Gatch is because it can increases the risk for blood clots