FRACTURE

Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.

2. Apply an ice pack for 10 minutes and remove for 20 minutes. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid

a client returns from the first session of scheduled physical therapy sessions following total knee replacement surgery. the nurse assesses that the client's knee is swollen, slightly erythematous, and painful. the client rates the pain as 7/10 & has not had any scheduled for PRN pain medication today. which of the following are appropriate nursing interventions? select all that apply 1. gently massage the area to increase circulation to reduce pain 2. administer pain medication as prescribed 3. elevate the leg and apply a cold pack 4. notify the the physician 5. call physical therapy to cancel the next treatment

2. administer pain medication as prescribed 3. elevate the leg and apply a cold pack Note: massage the are to increase circulation will INCREASE the pain.

prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. which of the following information is most important to include int eh teaching plan at this time? 1.teaching how to prevent hip flexion 2. demonstrating coughing and deep-breating techniques 3. showing the client what an actual hip prosthesis looks like 4. assessing the client's fears about the procedure

4. assessing the client's fears about the procedure

following a total hip replacement, the nurse should position the client in which of the following ways? 1.place weights alongside the affected extremity to keep the extremity from rotating. 2. elevate both feet on 2 pillows 3. keep the lower extremities adducted by use of an immobilization binder around both legs 4. keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs

4. keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs

which information should the nurse include when performing discharge teaching w/a client who had an anterolateral approach for a total hip replacement? select all that apply 1. avoid turning the toes / knee outward 2. use an abduction pillow between the legs when in bed 3. use an elevated toilet seat & shower chair 4. do not extend the operative leg backwards 5. restrict motion for 2 weeks after surgery

1. avoid turning the toes / knee outward 3. use an elevated toilet seat & shower chair 4. do not extend the operative leg backwards

a client who has a total hip replacement has a disclotated hip prosthesis. the nurse should first: 1. stabilize the leg w/ Buck's traction 2. apply an ice pack to the affected hip 3. position the client toward the opposite side of the hip 4. notify the orthopedic surgeon

4. notify the orthopedic surgeon

the nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. which of the following are expected normal findings? select all that apply 1. reduced edema of the left knee. 2. skin warm to touch 3. capillary refill response 4. moves toes 5. pain absent 6. pulse on left leg weaker than right leg

1. reduced edema of the left knee. 2. skin warm to touch 3. capillary refill response 4. moves toes Notes: Normal neurovascular findings include: 1. color normal; 2. extremity warm, 3. capillary refill less than 3 seconds, 4. moderate edema, 5. tissue not palpably tense, 6. pain controllable, 7. normal sensations, no paresthesia, normal motor abilities, normal motor abilities, no paresis / paralysis, and 8. pulses strong and equal.

the nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip replacement. the nurse instruct the client about which of the following? select all that apply 1. report promptly any difficulty breathing, rash, or itching 2. notify the health care provider of unusual bruising 3. avoid all aspirin-containing medications 4. wear or carry medical identification 5. expel the air bubble from the syringe before the injection 6. remove needle immediately after mediation is injected

1. report promptly any difficulty breathing, rash, or itching 2. notify the health care provider of unusual bruising 3. avoid all aspirin-containing medications 4. wear or carry medical identification Note: the air bubble should not be expelled fro the syringe because the bubble ensures the client received the full dose of the medication. the client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site

the nurse is assessing a client who had a left hip replacement 36 hours ago. which of the following indicates the prosthesis is dislocated? select all that apply 1. the client reported a "popping" sensation in the hip 2.the left leg is shorter than the right leg 3. the client has sharp pain in the groin 4. the client cannot move the right leg 5.the client cannot wiggle the toes on teh left leg

1. the client reported a "popping" sensation in the hip 2.the left leg is shorter than the right leg 3. the client has sharp pain in the groin Note: signs of prosthesis dislocation include: 1. acute groin pain in the affected hip 2. patient report "popping" sensation in the hip Toe wiggling is not a test for potential hip dislocation

The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client on the affected leg using pillows to support the other leg

2. Ensure the weights of the Buck's traction are off the floor and hang freely.

a client had a posterolateral total hip replacement 2 days ago. what should the nurse include int eh client's plan of care? select all that apply 1. when using a walker, encourage the client to keep the toes pointing inward 2. position a pillow between the legs to maintain abduction 3. allow the client to be in the supine position or in the lateral position on the unoperated side 4. do not allow the client to bend down to tie / slip on shoes 5. place ice on the incision after the physical therapy

2. position a pillow between the legs to maintain abduction 3. allow the client to be in the supine position or in the lateral position on the unoperated side 4. do not allow the client to bend down to tie / slip on shoes 5. place ice on the incision after the physical therapy

A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply. 1. The client requests pain medication to sleep. 2. The client has eupnea and normal sinus rhythm. 3. The client has petechiae over the neck and chest. 4. The client has a high arterial oxygen level. 5. The client has yellow globules floating in the urine.

3. The client has petechiae over the neck and chest 5. The client has yellow globules floating in the urine

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? 1. Assess the nailbeds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast.

1. Assess the nailbeds for capillary refill time.

The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three (3) times a day

1. Instruct the client to push the residual limb against a pillow.

The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement? 1. Monitor the continuous passive motion machine. 2. Apply thigh-high TED hose bilaterally. 3. Place the abductor pillow between the legs. 4. Encourage the family to perform ADLs for the client.

1. Monitor the continuous passive motion machine.

The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention? 1. T 99˚F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain.

2. Pain in the unaffected leg during dorsiflexion of the ankle.

The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse? 1. Capillary refill time is less than three (3) seconds. 2. Pain is not relieved by the patient-controlled analgesia. 3. Left fingers are edematous and the left hand is purple. 4. Warm and dry skin on left fingers distal to the elastic bandage.

2. Pain is not relieved by the patient-controlled analgesia.

the nurse is planning care for a group of clients who have had a total hip replacement. of the clients listed below, which is at HIGHEST risk for infection & should be assessed first? 1. a 55-year-old client who is 6 feet tall & weights 180 lb 2. a 90-year-old who lives alone 3. a 74-year-old who has periodontal disease with periodontitis 4. a 75-year-old who has asthma & uses an inhaler

3. a 74-year-old who has periodontal disease with periodontitis Note: infection is a serious complication fo total hip replacement & may necessitate removal of the implant.

the nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit during the first 6-8 weeks after surgery. which would be the correct type to recommend? 1. a desk-type swivel chair 2. a padded upholstered chair 3. a high-backed chair w/ armarests 4. a recliner w/ an attached footrest

3. a high-backed chair w/ armrests

A client has an intracapsular hip fracture. the nurse should conduct a focused assessment to detect: 1. internal rotation 2. muscle flaccidity 3. shortening of the affected leg 4. absence of pain the fracture area

3. shortening of the affected leg

in preparation for total knee surgery, a 200-lb (90.7-kg) client w/ osteoarthritis must lose weight. which of the following exercises should the nurse recommend as best if the client has no contraindications? 1.weight lifting 2.walking 3.aquatic exercise 4.tai chi exercise

3.aquatic exercise

The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

1. The client will maintain function of the leg.

a client is to have a total hip replacement. the preoperative plan should include which of the following? select all that apply 1. administer antibiotics as prescribed to ensure therapeutic blood levels 2. apply leg compression device 3. request a trapeze be added to the bed 4. teach isometric exercises of quadriceps and gluteal muscles 5. demonstrate crutch walking with a 3-point gait 6. place Buck's traction on the bed

1. administer antibiotics as prescribed to ensure therapeutic blood levels 3. request a trapeze be added to the bed 4. teach isometric exercises of quadriceps and gluteal muscles 5. demonstrate crutch walking with a 3-point gait

when preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information int eh discharge plan? select all that apply 1. report signs of infection to health care provider 2. keep the affected leg and foot on the floor when sitting in a chair 3. remove anti-embolism stockings when sleeping 4. the physical therapist will encourage progressive ambulation with the use fo assistive devices

1. report signs of infection to health care provider 4. the physical therapist will encourage progressive ambulation with the use fo assistive devices

the nurse is assessing a client for neurologic impairment after a total hip replacement. which of the following would indicate impairment in the affected extremity? 1. decreased distal pulse 2. inability to move 3. diminished capillary refill 4. coolness to the touch

2. inability to move others are for peripheral assessment. remember the "five P's"

a client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. the nurse should respond by saying which of the following? 1. "don't worry. your new hip is very strong." 2. "Use of a cushioned toilet seat helps to prevent dislocation" 3. "activities that tend to cause adduction of the hip tends to cause dislocation, so try to avoid them." 4. "decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation"

3. "activities that tend to cause adduction of the hip tends to cause dislocation, so try to avoid them."

The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the friend to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the friend's house and call 911.

3. Apply pressure to the radial artery of the left hand.

The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

3. Keep a large tourniquet at the client's bedside Note: 1. The client is in the recovery room, and the dressing must be assessed more frequently than every two (2) hours. 2. The client must come to terms with the amputation; therefore, the nurse should encourage the client to look at the residual limb. 3. The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally. 4. The nurse should encourage active, not passive, range-of-motion exercises. TEST-TAKING HINT: Remember to look at the phrases describing the intervention, such as "every two (2) hours" and "passive."

The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority. 1. Apply a sterile, normal saline-soaked gauze to the arm. 2. Send the client to radiology for an x-ray of the arm. 3. Assess the fingers of the client's right hand. 4. Stabilize the arm at the wrist and the elbow. 5. Administer a tetanus toxoid injection.

4, 1, 3, 2, 5 4. Stabilize the arm at the wrist and the elbow 1. Apply a sterile, normal saline-soaked gauze to the arm. 3. Assess the fingers of the client's right hand. 2. Send the client to radiology for an x-ray of the arm. 5. Administer a tetanus toxoid injection.

The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question? 1. Maintain heparin to achieve a therapeutic level. 2. Initiate and monitor intravenous fluids. 3. Keep the O2 saturation higher than 93%. 4. Administer an intravenous loop diuretic.

4. Administer an intravenous loop diuretic.

The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement? 1. Monitor the client's serum aPTT. 2. Encourage oral and intravenous fluids. 3. Do not eat foods high in vitamin K. 4. Administer in the anterolateral upper abdomen

4. Administer in the anterolateral upper abdomen

The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively? 1. Keep an abduction pillow in place between the legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees.

4. Sit in a high-seated chair for a flexion of less than 90 degrees.

The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client? 1. The client will maintain vital signs within normal limits. 2. The client will have a decrease in muscle spasms in the affected leg. 3. The client will have no signs or symptoms of infection. 4. The client will be able to ambulate down to the nurse's station

4. The client will be able to ambulate down to the nurse's station

The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client? 1. The occupational therapist. 2. The physiatrist. 3. The recreational therapist. 4. The home health nurse

4. The home health nurse

The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy

4. These macular lesions are from a latex allergy

after the knee arthroplasty, the client has a sequential compression device (SCD). the nurse should do which of the following? 1. elevate the SCD on the 2 pillows 2. change the settings on the SCD to make the client more comfortable 3.stop the SCD to remove dressings and bathe the leg 4. discontinue the SCD when the client is ambulatory

4. discontinue the SCD when the client is ambulatory

the laboratory notified the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 75 seconds. after verifying the values, the nuse calls the physician. the nurse should anticipate receiving a prescription for: 1. protamine sulfate 2. vitamin K 3. Warfarin (Cumadin) 4. Packed red blood cells

1. protamine sulfate Note: the aPTT is at a critical vale, & the client should receive protamine sulfate as the antidoe for heparin. vitamin K is the antidote for warfarin. packed red blod cells are administered to increase hematocrit