Ch 61

The amount of flexion for clients with hip replacements should never exceed ___° in a CPM machine.

30

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?

Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Explanation: The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

Which intervention should the nurse implement with the client who has undergone a hip replacement?

Instruct the client to avoid internal rotation of the leg. Explanation: The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. A pillow is used to keep the legs in abduction. The hip should not bend more than 90 degrees when seated. The head of bed should be kept at 60 degrees or less.

Which of the following is an inaccurate principle of traction?

Skeletal traction is interrupted to turn and reposition the patient. Explanation: Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely with the patient in good alignment in the center of the bed.

A patient with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply.

• Provide support to the injured extremity. • Prepare for cast removal. Correct Explanation: The nurse should anticipate immediate removal of the cast and provide support to the injured extremity. Neurovascular status should be assessed more frequently than every 8 hours. If the patient is not showing improvement in the neurovascular status, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above. Ice should not be used as it could further decrease blood flow to the extremity.

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?

Buck's extension traction Explanation: Buck's extension is used for fractures of the proximal femur. Russell's traction is used for lower leg fractures. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.

A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur?

Peroneal nerve Explanation: The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. Nerve function is assessed by observing the patient's ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may indicate peroneal nerve injury resulting from pressure at the head of the fibula.

(see full question) The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions?

• Decreased sensory function • Excruciating pain • Loss of motion Explanation: Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately.