Chapter 39 Fundamentals

When discharging a patient on crutches, it is imperative that he know there should be how much space to maintain between the top of the crutch and the axilla. When in the standing position with the elbow flexed 15-20 degrees and his/ her hands gripping the crutches, how far should the pads be below the axilla?

A. 4 inches B. 12 inches C. 1/2-2 inches or 3 finger breadths D. 6-8 inches or 4 finger breadths

Sharon is working on an orthopedic floor. How often should she inspect the casts for cracks, crumbling, pressure problems, and infections?

A. Every 2 hours B. every 4 hours C. every 6 hours D. every shift

Sharons patient has had restricted movement for a long time. One major complication Sharon's patient might develop is:

A. hypostatic pneumonia B. aspiration pneumonia C. paresthesia D. generalized weakness

Tims patient needs a lift to help him get into hydrotherapy. When using a lift, all of the following are true except:

A. one person can safely move a weak person this way B. you should never leave the patient unattended C. you should protect the lift with a sheet or bath blanket D. if a lift is soiled, you should use a disinfectant solution before using it again

Sharons patient has a continuous passive motion machine. This machine is used to:

A. turn the patient every 2 hours B. have her cough and deep breathe C. provide immobilization to a fractured area D. exercise the joint after a joint replacement surgery

Passive range-of-motion exercises are performed to prevent the problem of:

decreased joint mobility

A patient reports irritation of the skin under a fiberglass cast. What reason does the nurse suspect?

the cast got wet during bathing

While caring for a patient with a cast, the nurse elevates the cast on pillows. What is the reason for this?

to prevent the injured part from swelling

What is usually the first mechanical aid used when training an individual to walk after a stroke?

walker

A patient is at a risk for carpal tunnel syndrome. What can be used to immobilize the wrist of this patient?

wrist splint

A nurse is performing a neurovascular assessment for a patient with traction. The nurse asks the patient to move the area distal to the injury. Which response by the patient indicates that the fracture is healing?

⦁ "I feel no pain at all."

While teaching a patient to use axillary crutches, what is the most important instruction that the nurse gives the patient?

⦁ "adjust the height of the crutches a little slower."

What concern is most related to the psychosocial needs of a patient who has broken his leg?

⦁ Concerns about how he will look with a cast on

You are to perform range-of-motion exercises three times a day with your patient who is immobilized. Range-of-motion exercise promotes circulation by:

⦁ Contracting the muscles surrounding a vein, forcing blood to move toward the heart.

When assessing the patient with a new cast on the lower arm, if you find that the cast is tight and almost flush to the skin, you would first

⦁ Elevate the extremity on two pillows, making certain it is higher than heart level.

A nurse is using a mechanical lift to transfer an immobile patient from the bed to a wheelchair. What precautions should the nurse take during the process? Select all that apply.

⦁ Ensure that the wheels on the lift are locked. ⦁ Ensure all straps and life-securing devices are applied. ⦁ Ensure objects are out of the way before moving the patient

A nurse is caring for a patient with a cast on the left lower extremity. The nurse should do what?

⦁ Fold the stockinette over the outside edge of the cast to protect from chafing.

In addition to good skin care and frequent turning, measures that may help prevent development of pressure injuries in an immobilized patient are: (Select all that apply.)

⦁ Have family encourage the patient to perform active ROM exercises on unaffected extremities ⦁ Encourage adequate nutritional and fluid intake. ⦁ Keep the patient's skin clean and dry. ⦁ Place the patient on an air fluidized mattress.

Which type of commercial splint is used on an injured knee to prevent movement while an injury heals?

⦁ Immobilizer

6. You notice that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. You should:

⦁ Stop the machine and notify the primary care provider

While assessing a patient in cast, the nurse observes that the patient has an elevated temperature and reports pain in the injured part. What does this indicate?

⦁ There is an infection in the wound under the cast

A patient is at a risk for carpal tunnel syndrome. What can be used to immobilize the wrist of this patient?

⦁ Turn the patient every 2 hours ⦁ keep bed linen smooth and clean

7. The LVN is caring for a patient 5 days after falling and breaking his hip. The patient is bedridden and seems bored. The LVN should: (Select all that apply.)

Encourage family to visit several different times throughout the day. Assist patient in finding television programs of interest to him Offer newspaper and magazines for reading. 5. Increase dose of sleep aid so patient can sleep for longer intervals.

A cast that is too tight can directly cause: (Select all that apply.)

Pressure on nerves and nerve damage Constriction of blood vessels, decreasing circulation. Numbness and tingling in the extremity.