Musculoskeletal NCLEX

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus?

A clear chest x-ray is a favorable indicator that fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%. (Clear chest xray)

A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question?

A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.

The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching?

After TKR, the client should report signs and symptoms of infection or any changes in the shape of the knee, which could indicate developing complications. With a metal implant, the client requires anticoagulant therapy and should know to report adverse effects of this therapy, such as bleeding. The client should tell all caregivers about the metal implant because certain diagnostic tests will need to be avoided, and antibiotic prophylaxis will be needed before invasive procedures. ("I don't need to be worried if the shape of my knee changes." )

An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem?

Although all of these problems may apply to this client, lying supine, being older, and having cognitive impairment places the client at extreme risk for constipation and possibly impaction. The client likely does have disturbed thought processes because of the Alzheimer's disease and impaired tissue integrity because of the fracture. Because activity is restricted, activity tolerance is unknown. (constipation)

A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure?

An x-ray is a photographic image of a part of the body on a special film that is used to diagnose a wide variety of conditions. The x-ray itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area. (It is necessary to remove jewelry and any other metal objects.)

A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury?

Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse should assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active range of motion to an extremity that is fractured and in traction. (Check the neurovascular status of the affected extremity.)

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function?

Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin. (Provides comfort by reducing muscle spasms and provides fracture immobilization)

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes?

Clients with diabetes mellitus are at greater risk of wound infection and delayed wound healing because of this disorder. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it. (wound edges)

The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment?

Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Calf pain is a sign of this complication. Although bladder distention may occur postoperatively, option 3 is incorrect because it is not specific to the information in the question. Extremity lengthening or shortening may occur as a result of knee replacement but is not the highest priority. Additionally, heel breakdown is not the highest priority. (calf pain)

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?

Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion (ROM). The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful. (Performing ROM to the right ankle and knee)

The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction?

Following arthroscopy, signs and symptoms of infection such as fever or inflammation (redness or heat) should be reported to the health care provider. The client may resume the usual diet immediately. The arm does not have to be immobilized completely once sensation has returned, but the client usually is encouraged to refrain from strenuous activity for at least a few days. (Report to the health care provider the development of fever or redness and heat at the site.)

The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate?

Following total hip replacement, the hip incision may have a wound-suction drain in place, which is expected to drain usually less than 50 mL every 8 hours. The nurse should document the findings. The nurse may check the client's blood pressure, but this action is not directly related to the amount of drainage from the device. There is no need to call the health care provider immediately. Placing the leg flat in bed should be done only if prescribed by the health care provider. Additionally, this action is unrelated to the subject of the question. (document)

A client has just had an application of a nonplaster (fiberglass) leg cast, and the nurse is reinforcing instructions for cast care at home. Which statement by the client indicates the need for further teaching?

If a nonplaster cast gets wet, it should be dried with a hair dryer set only to a cool setting to prevent skin breakdown. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation. The client also should avoid walking on wet or slippery floors to prevent falls. It is acceptable to remove surface soil on a cast with a damp cloth. ("I should use a hair dryer set to the hot setting to dry my cast if it gets wet.")

A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy?

Iron preparations can be very irritating to the stomach and, to eliminate this problem from occurring, are best taken after a meal. They may also be taken 1 hour before a meal or between meals to enhance absorption. Health care provider preference will determine when the client should take the medication. The tablet is swallowed whole, not chewed. Because the client may experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. (medication following a meal)

A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved?

Local measures that help relieve bursitis (inflammation of a bursa) include joint rest, elevation, and the application of heat. Exercise is not helpful during the acute stage. In addition, nonsteroidal anti-inflammatory agents, analgesics, and short-term systemic corticosteroids may be prescribed. (Active intermittent range of motion)

The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client?

Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising. (Administering IM opioid analgesics)

A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client?

Option 3 identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Option 4 identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. In option 2, the nurse is offering a false reassurance, and this type of response will block communication. Option 1 is also a communication block and reflects a lack of the client's right to an opinion. ("You have concerns about skeletal versus skin traction for your type of fracture?")

The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin?

Osteomalacia is the softening of bone tissue characterized by inadequate mineralization of osteoid. It is the adult disorder equivalent of rickets and vitamin D deficiency in children. Therefore, options 1, 2, and 3 are incorrect. (Vitamin D)

The nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones?

Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur. The anatomical areas noted in options 1, 2, and 3 usually are not affected. (Axial skeleton including vertebrae)

The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching?

Postoperatively, depending on the type of surgical procedure, the client will have a bulky dressing in place for 4 to 7 days. The affected arm is elevated to reduce swelling. A sling is useful to limit movements and to keep the arm elevated. The sutures are removed in about 10 days after surgery. Within 2 to 3 weeks postoperatively, the client will begin physical therapy, with exercises to promote full range of motion of the wrist and prevent adhesion formation in the carpal tunnel. ("I should perform pronation and supination exercises of my wrist starting 24 hours after surgery.")

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints?

Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided. (small pillows)

The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client?

Tai chi is a slow, relaxed, and graceful series of movements. In tai chi, each movement flows into the next one and the entire body is always in motion, with the movements performed gently and at uniform speed. The upper arms often are held in a horizontal fashion. Clients who have had shoulder repair (rotator cuff repair) will not be able to lift the affected arm to perform the movements. Doing so can undo the surgical repair and cause the client severe pain. The client may be able to resume tai chi at some point in the future when permitted by the health care provider. ("You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the health care provider.")

Which intervention would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm?

The biopsy site would be elevated for 24 hours to reduce edema, not placed in a dependent position. Other aspects of care include monitoring the site for swelling, bleeding, and hematoma formation; monitoring vital signs; and administering analgesics for site discomfort. (Place the left arm in a dependent position for 24 hours.)

The nurse is reinforcing instructions to the client with a below-the-knee amputation (BKA) with regard to measures to protect the residual limb. The nurse should be sure to include which point in discussions with the client?

The client should use a mirror to visualize all areas of the residual limb after BKA. This will be most effective in helping the client detect any areas of redness or breakdown early. The client should not apply oils, creams, or lotions because they soften the skin too much for safe prosthesis use. The client should wear a clean woolen (not nylon) sock on the residual limb each day. The client should avoid using alcohol because it could cause drying or cracking of the skin. (Use a mirror to inspect all areas of the residual limb.)

A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client?

The client who has received a total knee replacement often has the leg put into a CPM machine while in the postanesthesia care unit. The device increases circulation and movement of the knee joint. It should be used as much as the client can tolerate. (as much as tolerated while in bed)

A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge?

The client with a new fracture that is casted with a plaster cast needs to avoid weight bearing. Option 2 is the only option that identifies a gait that allows non-weight bearing on the affected extremity. The client should not bear weight on the affected extremity until the health care provider evaluates the client on the follow-up examination. (three point gait)

The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food?

The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are available and recommended for those with typically low calcium intake. (cheese)

A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction?

The nurse should encourage analgesics in the postoperative client as needed. The nurse explains that the client will start to feel sensation as the spinal anesthetic wears off. Along with the increased sensation, the client will also experience pain. Although option 2 may be correct information, it does not address the issue of pain assessment. Option 1 is not appropriate because the nurse does not schedule the pain medication administration. Option 4 is incorrect because the client should be medicated before any activity is attempted, especially in the postoperative period. Also, following this type of surgery, the client should be using a fracture bedpan and should not be up to the bathroom. ("You will need to let me know when you start to get feeling back in your legs.")

The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder?

The stiffness and joint pain that occurs in osteoarthritis increase with activity and are relieved with rest. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Unlike rheumatoid arthritis, joint involvement is not usually symmetrical. Elevated white blood cell counts, platelet counts, and antinuclear antibodies occur in rheumatoid arthritis. (Pain that increases with activity and is relieved by rest)

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown?

There are specific areas that are under pressure and are at risk for breakdown in the client who has skeletal traction. These include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. (right heel)

The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain?

Uncontrolled musculoskeletal pain can result in harmful effects, resulting in certain assessment findings, such as weakness, fatigue, and immobility. Anorexia is associated with the gastrointestinal system; weight loss is associated with the endocrine system; and hypertension is associated with the cardiovascular system in terms of uncontrolled pain. (weakness)

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action?

When a client has skeletal traction, the priority is to assess the traction setup. The nurse must ensure that the weights on the traction setup are hanging free. If the weights are resting on or against any support, the purpose of the traction is defeated. Options 1, 2, and 4 are components of care; however, option 3 is the priority. (Ensuring that the weights on the traction setup are hanging free)

The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding?

Hypertrophy, or increased muscle size on the client's dominant side of up to 1 cm, is considered normal. Atrophy on either side is considered an abnormal finding. Fasciculations are fine muscle twitches that are not normally present.

The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?

A back brace or TLSO is individually fitted to the client. The brace should not irritate the skin with proper fitting. The brace is applied in the morning before getting out of bed. The closures should be secure but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin. (The device is applied beofre getting out of bed in the morning,

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance?

A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability.

The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first?

A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. (Check the clients alignment in bed.)

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next?

A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client and if ineffective, notifies the registered nurse, who will then contact the health care provider. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described. (notify the RN)

A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take?

A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client, and, if ineffective, then notifies the registered nurse, who then calls the health care provider (HCP). The nurse never removes traction weights unless specifically prescribed by the HCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described. (notify the RN)

The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?

After arthroscopy, the client can usually walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider. (Ill report fever or site inflammation to the health care provider)

The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action?

Because the victim complains of severe leg pain, a fracture should be suspected. With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. Before moving the client, the site of fracture is immobilized to prevent further injury. Moving the leg can cause further injury to the victim's leg. (Stay with the victim)

The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room?

Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room. (Anesthesia consent)

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device?

Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the health care provider. Skin traction does not involve pin care. (Inspecting the skin on the right leg at least once every 8 hours)

The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?

Client instructions should include avoidance of walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation. (If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting)

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?

Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Option 1 stretches the lower back. (In semi-Fowler's position with the knee gatch slightly raised)

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown?

Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. (Left heel)

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia, which does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. (Bleeding and swelling cause increased pressure in an area that cannot expand.)

The nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, "I hate looking at this; I feel that I'm not even myself anymore." The nurse understands that the client is experiencing which problem?

Disturbed body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client may also have the other problems listed in options 1, 2, and 4, but disturbed body image is the problem that correlates best with the client statement. (disturbed body image)

A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings, the nurse should take which action?

The client with early acute compartment syndrome typically complains of severe, diffuse pain that is unrelieved with pain medication.. The nurse notifies the registered nurse, who contacts the health care provider immediately. Options 2, 3, and 4 are inaccurate interventions. (notify the RN)

The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?

The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint for stability. The surgeon prescribes the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. (Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.)

The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed?

The nurse can best assist the client in skeletal traction with positioning in bed by providing a trapeze on the bed for the client's use. Encouraging the client to pull up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of positioning by the client. (Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.)

The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder?

The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify after activity, and they may be aggravated by cold, damp weather. No specific laboratory findings are useful in diagnosing osteoarthritis. Dull, aching pain occurs in the affected joints and, unlike rheumatoid arthritis, systemic manifestations are absent and joint involvement is not symmetrical. Morning stiffness, an elevated sedimentation rate, and a positive rheumatoid factor occur in rheumatoid arthritis. (Dull aching pain in the affected joints)

The nurse witnesses a client sustain a fall and may be fractured. Which action is the priority?

When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a health care provider is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. (Immobilize the leg before moving the client.)

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?

With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. Before moving the client, the site of the fracture is immobilized to prevent further injury.

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

A small amount of serous drainage is expected at pin insertion sites. (Serous drainage)

A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most?

A straight-leg cane is useful for the client with slight weakness in one leg. A walker is beneficial to the client with greater or bilateral weakness or who is at risk for falls. Wooden crutches are often used by clients with a leg cast. Lofstrand crutches aid clients who need crutches, but have limited arm strength.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward. Option 1 describes a swing-to gait. Option 2 describes the three-point gait used for a right leg problem. Option 4 describes a two-point gait. (Crutches and the left leg, then advance the right leg)

The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?

Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. (elevating the limb and applying ice to the affected leg.)

The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?

Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed. (Crutch tips will not slip even when wet)

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm?

Crutches are measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body. This could result in injury to the nerves of the brachial plexus. (Injury to the brachial plexus nerves)

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted?

Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (measurable by equal calf measurements and absence of pain or redness in the calf area), active baseline ROM to uninvolved joints, intact skin, and a bowel movement every other day. (BM every 5 days)

The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which findings does the nurse identify as early signs of possible fat embolism?

Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. Options 1, 2, and 4 are incorrect. (Increased heart rate and adventitious breath sounds)

Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching?

Following arthroscopy, the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return to the health care provider for follow-up in about 7 days. Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed. ("I can apply heat to my knee if it becomes uncomfortable.")

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed?

Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning. (Abductor splint)

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of which complication?

In this situation, the edema and the cast are compressing the structures within the leg. As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. The health care provider needs to be notified as soon as possible. Fat embolism may result from a fracture, but the client is not experiencing any signs or symptoms of this complication. Venous thrombosis may occur after fractures but would not affect sensation. Volkmann's contracture is a result of compartment syndrome in an upper extremity following a fractured humerus. (compartment syndrome)

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement?

Phantom limb sensations are felt in the area of the amputated limb. These can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, called "phantom limb pain." The origin of the pain is less well understood, but the client should also be prepared for this whenever possible. (It is a normal response and indicates the presence of phantom limb sensation.)

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor?

Risk factors associated with osteoporosis include a diet that is deficient in calcium. Postmenopausal age, family history, and long-term use of corticosteroids are risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide (Lasix). (High calcium diet consumption)

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infec

Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.

A client is treated in the health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours?

Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain. ( Application of heating pad)

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?

The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support, while the stronger side swings through. (Moves the cane when the right leg is moved)

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?

The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks, thus the client would not be supporting the weaker leg with the walker during ambulation. (The client advances the walker with reciprocal motion.)

The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement?

The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. (raised toilet seat)

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?

The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. (Moist, sterile saline dressings)

During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area?

The nurse is testing cerebellar function, specifically ataxia. Examples of disorders that include interferences in this area could be Parkinson's disease, multiple sclerosis, or brain attack (stroke). This test does not identify the problems addressed in any of the other options. (Balance and coordination)

The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity for which reason?

The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. The skin under the cast is not necessarily at risk for infection. The signs of other complications, such as fat embolism and skin infection, are not monitored by assessment of the neurovascular status of the casted extremity, but by other observations. The risk of compartment syndrome is related to internal or external causes of increased pressure in muscle compartments, rather than to the cast being wet. (Compartment syndrome may lead to irreversible nerve and muscle tissue injury.)

A client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which observation on inspection of the client's leg?

Typical signs and symptoms following femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain, or pain in the medial side of the knee. Moving the fractured extremity significantly increases the pain. (Shortening, adduction, and external rotation)

The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the client?

Vigorous or high-impact exercise could be damaging to articulating surfaces within joints and should be avoided by clients with osteoarthritis. The other options may be helpful in promoting joint mobility. (Increasingly vigorous and high-impact exercise)

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?

A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. (Elevate the leg on pillows continuously for 24 to 48 hrs.)

The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included?

Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 3 are also important, but physiological needs take precedence over psychosocial needs. (The client's vital signs, muscle strength, and previous activity level)

The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?

In addition to clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia greater than 7 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. (Uric acid level of 8 mg/dL)

The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which?

A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included, it is called a single hip spica; if two are included, it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.

The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure.

A pelvic sling is a traction device consisting of a hammock-like belt wherein the sling cradles the pelvis in its boundaries. It is used for the treatment of one or more pelvic fractures. Option 1 identifies a cervical halter skin traction. Option 2 identifies a pelvic belt traction. Option 4 identifies Russell's traction.

A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching. (I need to avoid getting the cast wet)

A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which?

Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Options 1, 2, and 4 are incorrect. (Muscle spasm in the area of the herniated disk.)

The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes?

Confusion in the older client with hip fracture could result from the unfamiliar hospital setting, stress from the fracture, concurrent systemic diseases, cerebral ischemia, or side effects of medications. Use of eyeglasses and hearing aids enhances the client's interaction with the environment and can reduce disorientation. (eyeglasses left at home)

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?

Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client. (Pillow to keep the right leg abducted during turning)

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure?

Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery. (overhead trapeze)

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?

Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal. Of the items listed in the options, pork would contain the least amount of calcium.

The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action?

If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the residual limb with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation. (Rewraps the residual limb with an elastic compression bandage)

The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan?

Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value. (Lift the left arm up over the head)

A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?

Low back pain with radiation into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing, or lifting the leg straight up while supine (straight leg raising test). Options 1, 3, and 4 assist in alleviating pain. (bending or lifting)

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?

Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. Options 1, 2, and 3 include secondary prevention measures. (Maintaining body weight at or above minimum recommended levels )

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?

Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and health care provider because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in. (Impaired tissue perforation)

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones?

Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur. (Axial skeleton including vertebraoe)

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast. (Petaling the cast edges with adhesive tape)

The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing which action?

The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. The sign in option 3 is indicative of the hip fracture itself. Option 2 indicates signs of infection, and option 4 indicates signs of severe circulatory impairment. (signs of dyspnea)

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service?

Following spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This individual will provide information about resources available to the client. The physical therapist has the best knowledge of techniques for increasing mobility and endurance. The clinical nurse specialist and surgeon do not have information related to financial resources. (Social worker)

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action?

An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. The nurse needs to obtain additional data in order to determine whether the health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay treatment if needed. (Check the neurovascular status of the toes on the casted leg.)

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply.

A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast. (Heat cannot be used on a plaster cast because the cast heats up and burns the skin.) The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The health care provider is notified immediately if circulatory impairment occurs.

A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed?

A quad cane may be used by the client requiring greater support and stability than is provided by a straight-leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for a client such as described in the question.

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?

A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking x-rays, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated.

The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done?

Clients are taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed, using one or both arms. The back is kept straight, and the legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects. (Get out of bed by sitting straight up and swinging the legs over the side of the bed.)

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?

Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The nurse should show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. (showing the client that cast cutter and explaining how it works.)

A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history?

Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact. (Separation of wound hedges)

The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action?

Clients with fractures are at risk for fat embolism. If the nurse suspects fat embolism, the nurse should place the client in a sitting (Fowler's) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The health care provider needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions. (Fowlers position)

The nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding?

For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101° F or higher should be reported because it might indicate infection or require that the hardware be removed. (oral temp of 101)

The nurse is caring for a client who had a below-the-knee amputation of the right leg. A cast that was placed on the residual limb has fallen off. Which action should the nurse take immediately?

If a cast or elastic dressing inadvertently comes off of the residual limb of a client with an amputation, the nurse immediately wraps the residual limb with an elastic compression bandage. If this is not done immediately, excessive edema will develop in a short time. The nurse does not replace a cast. The nurse should notify the surgeon if a cast comes off so that another cast can be applied. The nurse should document the occurrence and the actions taken. (Wrap the residual limb with an elastic compression bandage.)

The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate?

If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the health care provider. (Petal the cast edges with adhesive tape.)

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?

If the client in skeletal traction may not turn from side to side, the nurse should have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other. (asking the client to pull up on a trapeze to lift the hips off the bed)

The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?

Option 4 indicates that the client understands the purpose of the therapy and provides an incentive for the client to comply with the exercises. Option 1 may or may not be true and could relate to a number of factors other than use of the right hand. Option 2 is an inaccurate statement. Option 3 is incorrect because it indicates imposition of staff values on the client and is suggestive of possible abuse. ("I'm doing these exercises so I can begin to fasten my buttons and dress myself again.")

A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement?

Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. (Administer an analgesic)

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care?

Partial weight bearing usually is permitted 72 hours postoperatively. The client should keep her knees abducted with a wedge pillow. The client should not flex her hips any more than a 90-degree angle. Enoxaparin (Lovenox) is given by injection, not by a tablet. (Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.)

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance.

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?

The client is expressing concerns about appearance. The data in the question are unrelated to isolation and inability to tolerate activity. Although the client is unable to physically move about, this is not associated with what the client is upset about. (Concerns about apperance)

A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane?

The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe. (Left hand, and 6 inches lateral to the left foot)

The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply.

The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend their hips beyond 90 degrees; ensuring the client doesn't sit or stand for long periods of time; ensuring the client engages in walking and mild exercise to maintain strength; ensuring the client doesn't cross their legs past the midline of the body; and ensuring the client uses assistive/adaptive devices when performing activities of daily living. (Ensure the client does not sit or stand for long periods of time, Ensure the client does not cross the legs past the midline of body)

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action?

The client with pallor, slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. These signs can occur with constriction from a tight cast as well. Regardless of the cause, the nurse notifies the registered nurse immediately, who will contact the health care provider. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area. (notify the RN)

The nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?

The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. (numbness and tingling in fingers)

The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply.

The early signs of fat embolism include changes in the client's mental status or signs of impaired respiratory function caused by impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment are likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs of fat embolism. (mental statis, respiratory function)

The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting?

The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. (The client may bear weight on the cast in 30 minutes.)

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement?

The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid direct exposure of the skin to the sunlight. (I need to scrub the skin vigorously with soap and water)

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm?

Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the client with a vertebral fracture. The use of ice is incorrect because ice is applied to a site for only the first 24 hours after an injury. Application of ice to the spine of a client could be uncomfortable, increase spasms, and result in feeling chilled. (cold)

A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury?

Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use. (Fracture)

The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?

When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture. (Leakage of clear fluid from the nose)