Med-Surg for Progression Exam

A client is to have a total hip replacement. What nursing actions should the preoperative plan include? Select all that apply.

Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require antiembolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per prescription.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

A nurse monitors a client receiving enoxaparin 30 mg subcutaneously b.i.d after hip replacement surgery. Which adverse reaction is the client most likely to experience?

Bleeding is the most common adverse reaction associated with enoxaparin. The drug isn't known to induce anaphylactic shock or bronchospasm, and hypersensitivity reactions are rare.

A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity?

Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise.

The nurse is teaching a client with osteoporosis about taking alendronate sodium. The nurse emphasizes that the client is to take the medication:

Clients are instructed to take alendronate on arising, 30 minutes before eating, with a full glass of water. Because it can cause severe esophageal irritation, the client must remain upright for 30 minutes after administration.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture?

Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?

Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.

Which nursing intervention is essential in caring for a client with compartment syndrome?

Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?

Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. Clients usually can get the recommended daily requirement of calcium by eating a varied diet. Osteoporosis doesn't show up on ordinary X-rays until 30% of bone has been lost. Bone densitometry, however, can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than 35 who are at risk for osteoporosis. Strenuous exercise won't cause fractures. Although supplements are available, they aren't always necessary.

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching?

Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there.

An older adult is admitted with a fracture of the femur. The nurse should first assess:

The nurse first assesses the mechanism of injury to help determine related injuries, tests needed, and potential treatment options. The next step is to assess the location, type, quality, and intensity of the pain. Neurovascular stasis of the injured site is assessed after pain; therefore, the nurse checks for functional ability or changing positions. Although the nurse can also determine the extent of anxiety while assessing the injury and can use communication strategies to minimize anxiety, it is not the first priority for assessing this client.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

In preparation for total knee surgery, a 200-lb (90.7 kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications?

When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include:

With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.

Following a client's total hip replacement, what should the nurse do? Select all that apply

Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

An older adult is being admitted to the hospital after falling from a 6- foot ladder. Which information is essential for the nurse to obtain at this time? Select all that apply.

The acronym SPLATT (symptoms, previous fall, location, activity at the time, time, and trauma) can guide the assessment of an older adult who has fallen. It may be helpful to know if there was someone with the person when the fall occurred to present a bystander's perspective, but the information is not necessary and it is more important to get the client to describe in his or her own words what happened.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

To prevent external rotation of the client's hips while lying on the back, it would be best for the nurse to place:

Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips. Pillows can be used only as a temporary measure because they cannot hold the legs and hips in proper alignment over a prolonged period. Placing sandbags from the knees to the ankle will not effectively support the hips in proper alignment. A footboard does not help to keep the legs and hips in proper alignment.

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses the following: respirations are 30 per minute and are rapid and shallow; presence of faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. The nurse should first:

The nurse's first action is to notify the HCP because the client is likely experiencing a fat embolus. Fat emboli are associated with embolization of marrow or tissue fat or platelets and free fatty acids to the pulmonary capillaries, producing rapid onset of symptoms. Multiple fractures and fractures of the long bones or pelvis increase a client's risk for developing a fat embolus; in addition, young adults between 20 and 30 years of age are at a higher risk for fat emboli with fractures. When fat emboli do occur, hypoxia results; therefore, it is most important the nurse assess changes in level of consciousness and observe changes in behavior such as restlessness and irritability. The nurse does not cut the cast; there is no indication that the casts are obstructing circulation. ABGs are used to confirm the diagnosis, not a chest x-ray. The client's behavior is a result of hypoxemia, not pain.

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk?

A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin?

A client who is allergic to cephalosporins may also be allergic to penicillin. For the same reason, penicillin must be used cautiously in clients who are allergic to cephamycins, griseofulvin, or penicillamine. Cross-sensitivity between penicillin and tetracyclines, aminoglycosides, and erthyromycins hasn't been observed.

Which nursing diagnosis takes highest priority for a client with a compound fracture?

A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

A client reports to the emergency department after experiencing pain in the left arm. The client reports that he extended his arms in an attempt to prevent a fall. Which fracture type does the nurse anticipate?

A Colles' fracture occurs in the distal radius. Falling with outstretched arms and hands may increase the risk of this type of fracture. A spiral fracture results from a twisting movement. A greenstick fracture is a bent and incomplete fracture commonly seen in children. A compound fracture results in the bone extending through the skin.

A client is brought to the emergency department after injuring his right arm in a bicycle accident. The orthopedic surgeon tells the nurse that the client has a greenstick fracture of the arm. What does this mean?

In a greenstick fracture, one side of the bone is broken and the other side is bent. A greenstick fracture also may refer to an incomplete fracture in which the fracture line extends only partially through the bone substance and doesn't disrupt bone continuity completely. (Other terms for greenstick fracture are willow fracture and hickory-stick fracture.) The fracture line extends through the entire bone substance in a complete fracture. A fracture that results from an underlying bone disorder, such as osteoporosis or a tumor, is a pathologic fracture, which typically occurs with minimal trauma. Bone fragments are separated at the fracture line in a displaced fracture.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care?

It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bedrest is not common in care and assistive devices are used only in the acute period.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first:

The nurse should mark the bloody drainage and observe it again in 10 minutes to assess if the bleeding is continuing. There is no need to notify the health care provider immediately because some oozing and bloody drainage are expected. A fresh postoperative dressing should not be changed unless the health care provider prescribes it. Although the wound edges will be closed, no epithelialization has occurred yet to protect the deep tissues. Undressing the wound at this point increases the risk of a wound infection. Given the slight amount of drainage, there is no need to reinforce the dressing.

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying?

The client should be repositioned every 2 hours to promote even drying of the cast. The cast should be kept uncovered while drying to allow air to circulate around the cast and prevent heat from building up within it. It takes 24 to 72 hours for a plaster cast to dry; using a blow dryer may cause a heat burn and does not reduce the time for the cast to dry. The palms of the hands, not the fingers, should be used to move a drying cast in order to prevent indentations that can cause pressure points to develop.

A client is in the advanced stages of osteoarthritis. Which statement best describes the pain that occurs in the advanced stage of the disease?

In the advanced stages of osteoarthritis, pain can occur with minimal activity or even when the client is at rest. Crepitation can be present at any stage of the disease and does not exacerbate pain. Joints are not symmetrically affected by the disease. Symmetric joint involvement and fatigue are characteristics of rheumatoid arthritis.

After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching?

The client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, that could lead to skin irritation and breakdown. Applying lotion is not recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow). Applying extra padding (e.g., to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder and lotion is not recommended, because they can cause irritation and skin breakdown.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.