Chapter 28

The nurse is caring for a patient with a lateral approach left hip arthroplasty. Which action should the nurse take?

Do not let the patient bend forward when getting out of bed.

The nurse is caring for a patient in tongs. Which area would the nurse monitor closely?

Head

The nurse is checking the patient's incision from knee surgery. Which finding indicates the incision is healing?

Incision edges approximated

The nurse is caring for a patient with a total hip replacement. Which instruction should the nurse reinforce to the patient?

Keep the back straight when getting out of bed.

Which health-care team member is priority when working with a patient in rehabilitation after an amputation?

The physical therapist (PT)

In which area should the nurse start a figure-of-eight wrap on a patient's foot?

Under the arch of the foot

How would the nurse care for the pin sites (shown in the image)?

Use sterile gauze with normal saline to clean the site.

The nurse suspects wound dehiscence in a patient who had knee surgery. What did the nurse observe?

A gaping wound

Which patient would the nurse most likely observe using a knee scooter?

A patient who has a broken ankle

Which crutch gait would the nurse reinforce to a patient who is unable to bear weight on the right broken foot?

A three-point gait

The nurse is caring for a patient in tongs. Which strategy should the nurse use?

Allow time to discuss altered body image.

The nurse is assisting the registered nurse (RN) in caring for a recent postoperative patient who had a total hip replacement. The patient's dressing has a moderate amount of drainage. What should the nurse do?

Check beneath the patient's hip for blood.

The nurse is performing a neurovascular check on a patient after hip surgery. Which areas would the nurse monitor? Select all that apply.

Check skin temperature Check for tingling Check the ability of the patient to move toes Check capillary refill

Which term would the nurse use in report to describe a patient's fracture that broke into many small pieces?

Comminuted

The nurse is assisting the registered nurse (RN) in caring for a recent postoperative patient who had an amputation of the left leg. Which finding would alert the nurse of possible hemorrhage and shock?

Decreasing blood pressure and increasing pulse rate

The health-care provider's prescription for the continuous passive motion (CPM) machine is as follows: settings of 30° of flexion at 10°/min to start and advance to 70° of flexion at 30°/min as tolerated. It is now day two. At which setting should the CPM machine be set?

Forty degrees of flexion at 20°/min

The nurse working in a long-term care facility is helping residents maintain mobility. Which action is the nurse taking?

Increasing the time that residents are sitting in chairs

The nurse is caring for a patient in traction. Which action should the nurse take?

Keep the ropes straight on the pulleys

The nurse is using a figure-of-eight wrap on a patient's ankle. Which technique should the nurse use?

Make each addition wrap one-quarter to one-half inch (0.51 to 1.3 cm) more proximal than the previous wrap

Which patient information would cause the nurse to question an order for a magnetic resonance imaging (MRI)? Select all that apply.

One who has a phobia of enclosed spaces One who has a metal plate in the head One who has a pacemaker for heart block

The nurse is preparing a patient for a computed tomography (CT) scan. The nurse is most likely caring for which patient?

One who has congenital abnormalities of the musculoskeletal system

The nurse is caring for a patient who has an Ilizarov frame. The nurse is most likely caring for which patient?

One whose left leg is shorter than the right after a vehicle accident

The nurse is placing a patient's leg into a continuous passive motion (CPM) machine. Which sequence would the nurse follow?

Place the CPM machine on the bed. Place the sheepskin on the platform. Place the patient's leg in the machine. Set the degree of flexion. Turn the machine on. Observe the machine as it flexes and extends.

The nurse and the unlicensed assistive personnel (UAP) are caring for a patient after a direct anterior approach for a hip replacement. Which action by the UAP would cause the nurse to intervene?

Placing an abduction pillow between the patient's legs

The nurse is contributing to the plan of care for a patient with a continuous passive motion (CPM) machine after left knee surgery. Which intervention should the nurse recommend including in the patient's plan of care?

Position the break in the platform beneath the patient's popliteal area.

The nurse is reinforcing teaching with a patient about the hip joint. Which information should the nurse include?

Synovial fluid lubricates the joint.

The nurse is contributing to the plan of care for a patient with a total right knee replacement. Which interventions should the nurse recommend including in the plan of care? Select all that apply.

Test sensation of both legs by using a paper clip. Observe the color of the skin in the lower right leg and feet. Ask patient to move toes on the right leg

A patient with a weak left leg is using a walker. Which patient finding would the nurse praise?

The patient moves the left leg with the walker, then the right.

The nurse wraps a patient's elbow. Which findings would cause the nurse to rewrap the bandage more loosely? Select all that apply.

The patient states that they cannot feel their fingers. The patient cannot move their fingers. The patient's fingers are slightly blue.

The home health nurse (HHN) is caring for an older adult patient in the home. Which patient information would cause the nurse to talk to the nursing supervisor to consider a physical therapy consult?

The patient states, "I'm not as steady on my feet as I used to be."

The health-care provider prescribed the continuous passive motion (CPM) machine to be used 1-2 hr tid. How often should the patient be placed in the CPM machine?

Three times a day

A patient has a direct anterior approach for a total hip replacement. In which area would the nurse collect data about the incision?

Top of the hip

The nurse walks into the room and observes a patient (shown in the image). The nurse would focus interventions based on which type of surgery?

Total knee replacement

The nurse is caring for a patient in a plaster cast that is drying. Which action should the nurse take?

Use palms to position the cast.

The nurse is caring for a patient with crutches from a broken right leg. Which instruction should the nurse reinforce?

When walking up the stairs, place the left leg first, then the crutches and the right leg

The nurse is reinforcing teaching with a mother of a child who has a sprained ankle. Which statements by the mother would indicate a correct understanding of the teaching? Select all that apply.

"I should let the child rest." "I will place ice on the ankle." "I will make sure the bandage stays in place." "I will put pillows under my child's ankle."

How should the nurse describe a figure-of-eight wrap to a patient?

"It is like a crisscross pattern."

Which information should the nurse share with a patient about skin traction?

"It will help decrease muscle spasms."

The patient with a leg amputation asks the nurse why a compression sock is used. What is the nurse's best response?

"This helps mold the stump to fit the artificial leg."

The nurse is assisting the registered nurse (RN) in developing a plan of care for a patient with impaired mobility from hip replacement surgery. Place in order the necessary steps.

(1) observe patient after surgery moaning and saying that pain is at a level 8 on the 0-10 scale (2) contribute data to the development of acute pain nursing diagnosis (3) plan outcome to reduce pain to at least a 4 on a 0-10 scale (4) encourage pain medication and deep breathing (5) ask the patient to rate pain level after interventions.

A patient is having a follow up at the clinic for a cast. The patient reports itching under the cast. What would the nurse suggest?

Set a smaller hair dryer on the cool setting.

The nurse is contributing to the plan of care for a patient with a cast. Which interventions should the nurse recommend including in the patient's plan of care? Select all that apply.

Observe for drainage. Check for a malodorous smell. "Petal" the edges of the cast if crumbling.

Which nursing actions would the nurse take for this patient (shown in the image)? Select all that apply.

Ensure that weights hang freely Check the circulation to the foot. Monitor for skin breakdown

The nurse is observing a patient with a weak left leg walk with a cane. Which patient action indicates a correct understanding of using a cane?

Moves the left leg and cane together, then the right leg

The nurse is checking the neurovascular status in a patient with a casted arm. Which findings would the nurse report to the registered nurse (RN) or health-care provider? Select all that apply.

Numbness in fingers Increasing edema Pale nailbeds Capillary refill 6 seconds

The nurse is caring for a postoperative patient with a hip arthroplasty. Which action by the patient indicates appropriate pain management by the nurse?

Rates the pain as a 3 on a 0-10 scale

Which actions should the nurse take when caring for patients with musculoskeletal issues? Select all that apply.

Reinforce going down the stairs to start with the affected leg and crutches. Make sure the walker hand brakes are pulled down before the patient sits in a walker seat Position the quad cane 4 in. (10 cm) away from the side of the foot.

A patient has returned from surgery after a right knee replacement. Which pulse is priority for the nurse to monitor for impaired circulation?

Right pedal pulse

A patient returns from a total knee replacement surgery. The patient has a 0.9% normal saline running at 100 mL/hr. The right knee dressing is in place. Which findings would cause the nurse to follow up? Select all that apply.

The health-care provider's prescription is 5% dextrose and 0.9% sodium chloride at 100 mL/hr. The capillary refill is sluggish. The pedal pulse is weak in the right leg when compared to the left.