Musculoskeletal UWORLD

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider immediately? 1. Distended abdomen and absent bowel sounds 2. Ecchymosis over the pelvic bones 3. Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) 4. Tenderness over the right heel

1

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary? 1. "I will concentrate on leaning forward as I carefully sit down in a chair." 2. "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." 3. "I will use the sock puller that the therapist gave me when I get dressed." 4. "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!"

1

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likelyexpect? Select all that apply. 1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 3. Internal rotation of the affected extremity 4. Muscle spasm around the affected area 5. Shortening of the affected extremity

1,2,4,5

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice

1

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed 3. Loosens the Velcro straps when the client reports that the boot is too tight 4. Provides the client with a fracture pan for elimination needs

1

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? 1. Stay with the victim. 2. Assist the victim out of the automobile. 3. Leave the victim to call an ambulance. 4. Tell the victim to keep moving the leg to maintain circulation.

1 (Rationale: The appropriate nursing action is to stay with the victim. 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. While staying with the victim the nurse should 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.)

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? 1. Notify the registered nurse. 2. Reassess the client in 30 minutes. 3. Check to see whether it is time for more pain medication. 4. Encourage the client to continue with active range-of-motion exercises to the left arm.

1 (Rationale: 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 primary health care provider immediately. The other actions are inaccurate interventions.)

GOOD The nurse is caring for a client who was just admitted with a diagnosis of fractured right femur. What are some of the acute complications the nurse needs to assess for? *Select all that apply.* 1. Crush syndrome 2. Ischemic necrosis 3. Fat embolism syndrome 4. Arterial thromboembolism 5. Acute compartment syndrome (ACS) 6. Hemorrhage and hypovolemic shock

1, 3, 5, 6 (Rationale: The nurse monitors the client for acute complications of fractures such as crush syndrome, fat embolism syndrome (FES), acute compartment syndrome (ACS), and hemorrhagic and hypovolemic shock. Infection is also another acute complication of fractures. Venous and not arterial thromboembolism is also an acute complication that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). Ischemic necrosis is a chronic complication. Clinical manifestations of beginning complications must be treated early to prevent serious consequences.)

GOOD An elderly 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 is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? *Select all that apply.* 1. Osteoporosis 2. Foot disorders 3. Bony metastases 4. Carpal tunnel syndrome 5. Diminished visual acuity 6. Changes in cardiac function

1,2,3,6 1. Osteoporosis 2. Foot disorders 3. Bony metastases 6. Changes in cardiac function (Rationale: Disease processes like osteoporosis, foot disorders, bony metastases, and changes in cardiac function increase the older adults' risk for hip fracture. A history of carpal tunnel syndrome does not affect the elderly client's risk for hip fracture. Diminished visual acuity is a sensory, physiological change that can occur in the older adult and is not a disease process. Test-Taking Strategy(ies): Knowledge of the subject, hip fractures in the elderly will help in choosing the correct options. Eliminate carpal tunnel syndrome first because this condition is related to the hands and does not increase one's risk for falls. Also, diminished visual acuity is a normal sensory change related to aging. The other disease processes are correct.)

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply. 1. Confusion and restlessness 2. Increasing pain despite the opioid analgesia 3. Paresthesia of the affected extremity 4. Petechiae over neck and chest 5. Pulse oximeter showing hypoxia

1,4,5 1. Confusion and restlessness 4. Petechiae over neck and chest 5. Pulse oximeter showing hypoxia

A nurse working in the office of a health care provider (HCP) must respond to client telephone messages. The nurse should return which call first? 1. Client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone 2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot 3. Client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting 4. Client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

2

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus? 1. Minimal dyspnea 2. Clear chest x-ray 3. Oxygen saturation 85% 4. Arterial oxygen level of 78 mm Hg

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

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*? 1. Provide pin care. 2. Check the client's alignment in bed. 3. Medicate the client with an analgesic. 4. Call the primary health care provider (PHCP).

2 (Rationale: A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. 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.)

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2 (Rationale: A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.)

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? 1. Intact skin surfaces 2. Bowel movement every 5 days 3. Equal calf measurements bilaterally 4. Active range of motion (ROM) of uninvolved joints

2 (Rationale: 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.)

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? 1. Administer an analgesic. 2. Notify the registered nurse. 3. Check the circulation again in 30 minutes. 4. Provide range-of-motion exercises to the fingers of the left hand.

2 (Rationale: 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. Regardless of the cause, the LPN notifies the registered nurse immediately, who will contact the primary health care provider. These signs can occur with constriction from a tight cast as well. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area.)

GOOD The nurse has provided instructions to a client in an arm cast about the signs/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? 1. Cold, bluish fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is relieved only by an opioid analgesic

2 (Rationale: 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.)

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? 1. Provide pin care. 2. Notify the registered nurse. 3. Remove some of the traction weights. 4. Find out when the next dose of the prescribed analgesic can be given.

2 (Rationale: The nurse realigns the client, and, if ineffective, then notifies the registered nurse, who then calls the primary health care provider (PHCP). A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse never removes traction weights unless specifically prescribed by the PHCP. 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.)

GOOD 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 *early* signs of this complication by checking which criteria? *Select all that apply.* 1. The client's renal system 2. The client's mental status 3. The client's mobility status 4. The client's respiratory function 5. The client's cardiovascular system

2, 4 (Rationale: The earliest signs/symptoms of fat embolism include changes in the client's mental status or signs/symptoms 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/symptoms of fat embolism.)

The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli? 1. Administering prophylactic enoxaparin as prescribed 2. Frequent use of incentive spirometry 3. Minimizing movement of the fractured extremity 4. Use of an intermittent pneumatic compression device

3

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 activities in the care of the client? *Select all that apply.* 1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living.

2,4,5 (Rationale: 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 his/her hips beyond 90 degrees and not 120 degrees, doesn't sit or stand for long periods of time, and doesn't cross his/her legs past the midline of the body. The nurse should ensure that the client engages in walking and mild, not rigorous, exercise to maintain strength and that the client uses assistive/adaptive devices when performing activities of daily living.)

A client with a hip fracture is placed in Buck's traction. Which nursing intervention is most important when caring for this client? 1. Keeping the extremity above the client's heart level 2. Pain assessment and analgesia use every 2 hours 3. Skin assessments every 2-4 hours 4. Turning the client, using an abduction pillow, every 2 hours

3

GOOD 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? 1. A bone fragment has injured the nerve supply in the area. 2. An injured artery causes impaired arterial perfusion through the compartment. 3. Bleeding and swelling cause increased pressure in an area that cannot expand. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

3 (Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment triggering the signs/symptoms.)

GOOD 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 finding does the nurse identify as *early* signs/symptoms of possible fat embolism? 1. Decreased heart rate and increased restlessness 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Increased heart rate and increased oxygen saturation

3 (Rationale: Early signs/symptoms of possible fat embolism are increased heart rate and adventitious breath sounds. Fat embolism commonly causes signs/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. The other findings are incorrect.)

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? 1. Footboards 2. Large pillows 3. Small pillows 4. Soft mattress

3 (Rationale: 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.)

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? 1. Dry, sterile dressings 2. Hydrocolloid dressings 3. Moist, sterile saline dressings 4. Half-strength povidone-iodine dressings

3 (Rationale: 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. The other types of wound care are incorrect.)

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be *most* concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

3 (Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.)

A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? 1. Check the blood pressure. 2. Check the pin sites for drainage. 3. Check the neurovascular status of the affected extremity. 4. Monitor the client's ability to perform active range of motion to the affected extremity.

3 (Rationale: The nurse would check the neurovascular status and assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Bone fragments and tissue edema associated with a fracture can cause nerve damage. 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.)

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the *priority*? 1. Take a set of vital signs. 2. Call the radiology department. 3. Immobilize the leg before moving the client. 4. Reassure the client that everything will be fine.

3 (Rationale: 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 PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.)

The nurse is caring for a woman with obesity who is 3 days postoperative total hip joint replacement. Which laboratory value is of greatest concern and should be reported to the health care provider (HCP) immediately? 1. Blood urea nitrogen (BUN) 22 mg/dL (7.9 mmol/L) 2. Glucose 158 mg/dL (8.7 mmol/L) 3. Hematocrit 33% (0.33) and hemoglobin 11 g/dL (110 g/L) 4. White blood cell count (WBC) 16,000/mm3 (16.0 ×109/L)

4

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? 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours, and put it flat for 1 hour. 3. Keep the leg level for 3 hours, and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.

4 (Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. Therefore, the other options are incorrect.)

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? 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4 (Rationale: 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.) (Test-Taking Strategy(ies): Note the strategic word, primary, and focus on the subject, the function of Buck's extension traction. Recalling the purpose of traction will assist in eliminating options 1 and 3. From the remaining options, eliminate the option with the words rigid immobilization.)

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? 1. Ensure the client receives the daily tablet of enoxaparin. 2. Assist the client in keeping the legs as close together as possible. 3. Remind the client to use a handrail when lowering the hips into a 120-degree flexion. 4. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.

4 (Rationale: Partial weight bearing usually is permitted 72 hours postoperatively per surgeon's preference but the nurse needs to check the surgeon's prescription. The client should keep the knees abducted with a wedge pillow. The client should not flex the hips any more than a 90-degree angle. Enoxaparin is given by injection, not by a tablet.)

GOOD 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 signs/symptoms are indicative of which complication? 1. Fat embolism 2. Venous thrombosis 3. Volkmann's thrombosis 4. Compartment syndrome

4 (Rationale: The client's signs/symptoms are indicative of compartment syndrome. 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 primary 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/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)

The nurse is preparing a plan of care for a client in skeletal leg traction with an over bed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2. Place a draw sheet under the client for pulling the client up in bed. 3. Encourage the client to pull up by pushing with the unaffected leg on the bed mattress. 4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

4 (Rationale: 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.)

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? 1. Try to manually reduce the fracture. 2. Assist the person with getting up and walking to the sidewalk. 3. Leave the person for a few moments to call an ambulance. 4. Stay with the person and encourage the person to remain still.

4 (Rationale: 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. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.)

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? 1. Document the findings. 2. Place the leg in a flat position. 3. Check the client's blood pressure. 4. Immediately notify the registered nurse.

1 (Rationale: 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 notify the registered nurse immediately, although this information may need to be conveyed to the registered nurse at the end of the work shift. Placing the leg flat in bed should be done only if prescribed by the primary health care provider. Additionally, this action is unrelated to the subject of the question.)

GOOD The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the *early* manifestations of this syndrome? *Select all that apply.* 1. Fever 2. Dyspnea 3. Petechiae 4. Hypoxemia 5. Tachypnea 6. Decreased level of consciousness

2, 4, 5 2.Dyspnea 4. Hypoxemia 5.Tachypnea (Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop.)

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? 1. "There is no reason to be concerned. I have seen lots of these procedures." 2. "Skeletal traction is much more effective than skin traction in your situation." 3. "You have concerns about skeletal versus skin traction for your type of fracture?" 4. "Your fracture is very unstable. You will die if you don't have this surgery performed."

3 (Rationale: Asking the client if there are concerns about skeletal versus skin traction identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Telling the client the fracture is unstable and you will die if you don't have this surgery, identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. Also, saying that skeletal traction is more effective than skin traction is offering a false reassurance, and this type of response will block communication. In addition, saying that there is no reason to be concerned is also a communication block and reflects a lack of the client's right to an opinion.)

GOOD 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? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The newness of the fracture

3 (Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP 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.)

The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction? 1. Resume regular full activity the following day. 2. Do not eat or drink anything until the following morning. 3. Keep the shoulder completely immobilized for the rest of the day. 4. Report to the registered nurse the development of fever or redness and heat at the site.

4 (Rationale: Following arthroscopy, signs/symptoms of infection such as fever or inflammation (redness or heat) should be reported to the registered nurse who will perform an assessment and contact the primary 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.)

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? a. Maintain immobilization and alignment. b. Provide optimal nutrition and hydration. c. Promote independence in activities of daily living. d. Provide relief from pain and discomfort.

Correct answer: A Maintaining the prescribed immobilization and body alignment will keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing. According to the safety and risk reduction priority setting framework, this goal should receive the highest priority. While important for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework. While appropriate for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework. While necessary for the care of a client who has a fracture, this intervention is not the highest priority according to the safety and risk reduction priority setting framework

When admitting a client with a fractured extremity, the nurse should FIRST assess: a. The area proximal to the fracture b. The actual fracture site c. The area distal to the fracture d. The opposite extremity for baseline comparison

Correct answer: C While assessing the fracture site is important- it is most important to assess for neurovascular status distal to the fracture site to get a baseline and know how well the peripheral limb is getting blood flow

GOOD 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/symptoms of fat embolism. The nurse provides appropriate care by performing which action? 1. Monitoring for signs of dyspnea 2. Monitoring the client's temperature regularly 3. Maintaining external rotation of the right leg 4. Educating the client to report paresthesia of the right lower leg

1 (Rationale: The signs/symptoms 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 of maintaining external rotation of the right leg is indicative of the hip fracture itself. Monitoring the temperature regularly indicates signs of infection, and telling the client to report paresthesia of the right leg indicates signs of severe circulatory impairment.)

The nurse is caring for a client who is 12 hours postoperative total hip replacement. Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis? 1. Instructing the client to cross the legs only at the ankles 2. Maintaining the head of the bed at ≥45-60 degrees 3. Placing an abductor pillow between the legs when turning the client 4. Turning the client to the affected side to alleviate lateral muscle pulling

3

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3 (Rationale: 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 PHCP 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.)

The nurse is caring for a client with a tibial fracture who was just diagnosed with acute compartment syndrome (ACS). Which procedure does the nurse anticipate the surgeon will perform? 1. Fasciotomy 2. Arteriotomy 3. Venous thromboectomy 4. External compartment removal

1 (Rationale: If ACS is verified, the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure and restores circulation to the affected area. Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Arteriotomy is a surgical opening into an artery. A venous thromboectomy is removal of a piece of clot or embolus from a vein. It is indicated in clients with deep vein thrombosis (DVT) whose symptoms are severe and present for fewer than 7 days. External compartment removal is not a surgical procedure.)

The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which *highest priority* assessment? 1. Calf pain 2. Heel breakdown 3. Bladder distention 4. Extremity shortening

1 (Rationale: The highest priority assessment that the nurse needs to monitor in this client is the presence of calf pain. 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, this assessment 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.)

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? 1. Trochanter roll to prevent abduction while turning 2. Pillow to keep the right leg abducted during turning 3. Pillow to keep the right leg adducted during turning 4. Trochanter roll to prevent external rotation while turning

2 (Rationale: 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.)

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*? 1. Provide pin care. 2. Medicate the client. 3. Notify the registered nurse. 4. Remove 2 pounds of weight from the traction.

3 (Rationale: 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, would next notify the registered nurse, who will then contact the primary health care provider. Severe leg pain once traction has been established indicates a problem. Medicating the client would be done after trying to determine and treat the cause. The nurse would never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described.)

GOOD 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? 1. Reassess the vital signs. 2. Perform a neurological assessment. 3. Place the client in a supine position. 4. Place the client in a Fowler's position

4 (Rationale: If the nurse suspects fat embolism, the initial action by the nurse is to place the client in a sitting (Fowler's) position to relieve dyspnea. Clients with fractures are at risk for fat embolism. Supplemental oxygen is indicated to reduce the signs of hypoxia. The primary 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.)

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? a. Change in temperature of the toes. b. Pallor of the toes. c. Edema of the toes. d. Inability to move toes.

Correct answer: B If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, the temperature of the toes will become cool to the touch. However, this is not the initial finding. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, edema will become present in the toes. However, this is not the initial finding. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation and nerve transmission. When this occurs, the client will lose the ability to move the toes. However, this is not the initial finding

1The 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 is the priority nursing action? a. Provide pin care b. Medicate the client c. Call the healthcare provider d. Remove 2 pounds

Correct answer: C Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? a. Administer an opioid analgesic. b. Obtain a prescription to adjust the weight amount. c. Offer a muscle relaxant to the client. d. Realign the client's position.

Correct answer: D The nurse should administer opioid analgesics to relieve pain that cannot be controlled with other measures; however, another action is the priority. The nurse should contact the provider to obtain a prescription to adjust the weight amount to relieve pain that cannot be controlled with other measures; however, another action is the priority. The nurse should offer the client a muscle relaxant to relieve pain that cannot be controlled with other measures; however, another action is the priority. The greatest risk to this client is injury form circulatory compromise and tissue damage; therefore, the first action the nurse should take is to realign the client's position