N13 Final Study

Which sign indicates that a client with a fracture of the right femur may be devo'g a fat embolus?

acute respiratory distress syndrome

Client with extracapsular hip fracture returns to the nursing unit after internal fixation with hip with a drainage tube. What is the purpose of the drainage tube?

Fluid will not be able to accumulate in the wound

NPSG

ICAMISS Id the patient Communication with staff Alarms Med safety Infection prevention Suicide risk Surgery mistakes

Electromyography

Info about electrical potential eval weakening, pain, disability assess for use of anticoags; electrodes may cause bleeding active skin infection

Nrs assesses that a pt is restless in the immediate p/o period. The nurse shld first:

administer oxygen restlessness in the immediate p/o may be a sign of cerebral hypoxia as a result of depression of the CNS

balanced traction

allows greater independence for the patient

Femoral Shaft/Neck Fracture

measure diameter of thigh for bleeding, immobilize, traction, splinting Thomas splint with Pearson traction Fat emboli nonweight bearing

Client with a fractured tibia has been taking methocarbamol. Which finding indicates that the drug is having the intended effect?

relief of muscle spasms

Laminectomy

removal of the laminar spine to relieve pressure on the spinal column

Ataxia and Buits

respiration changes that are of neuro orgins

Delayed Union

s/t distraction, infection, poor nutrition, co-morbidities surgical correction - internal stabilization osteogenesis stimulation by electrical impulses bone grafting noninvasive inductive coupling

The nurse devo a POC for a client in the initial p/o period following a lumbar laminectomy. Which activity is contraindicated

sitting all afternoon in her room

Shock - trauma pt w/hip fracture

stabilize restore blood vol pain management immobilize protect from complication

Fat Emboli

sudden restlessness and anxiety dyspnea

Humoral Shaft and Neck

support and immobilize ORIF Pendulum/circumduction after adequate immobilization

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 the front porch

Pt with TB is taking isoniazid; to help prevent peripheral neuritis the pt shld...

take supplemental pyridoxine (Vit B6)

Which nrs'g action would most likely be successful in reducing pleuritic chest pain in a pt with PNA?

teach to splint the rib cage when coughing

PEFR

600L Peak expiratory flow rate

Nrs is caring for Pt with bacterial PNA, the effectiveness of O2 therapy can best be determined by?

ABG values

Dislocation/Sprain

Avascular necrosis (Dislocation) RICE heat 24-72hr post injury

Client with a SC injury, experiencing blurred vision and bp 204/102. What shld nrs do first?

Check for bladder distention experiencing autonomic dysreflexia, which is a medical emergency, prepare for catheterization

After surgery and insertion of a total hip prosthesis, a client devo severe sudden pain and inability to move the extremity. These findings indicate?

Joint dislocation

Thoracolumbar fracture

No twisting x-ray to confirm check for neuro deficits limited motion and bed rest laminectomy

The nurse is teaching the client to admin enoxaparin following total hip replacement. What would the nurse instruct the client to do?

Report difficulty breathing, rash, itching Notify HCP of unusual bleeding Avoid all aspirin containing products Wear/carry med id

Client dx with septic arthritis in a hip joint. Which outcomes are desired from a client-focused teaching plan?

Report pain that is severe enough to limit activity discuss how to take prescribed meds describe septic arthritis physio explain importance of supporting the affected joint describe ambulatory aids and assistive devices

Total Knee Arthroscopy

Shave off the hard parts of the bone peroneal nerve palsy foot drop assess for infection and bleeding CPM

Pelvis Fracture (Stable/Unstable)

Unstable - assess for hemorrhage, injury to bladder and abdominal organs, focused GI assessment Stable - bedrest and pain management

Elbow fracture

Volkmann's Contractures - finger exercises acute compartment syndrome immobilize with cast/splint hemarthrosis - collection of blood in the joint

When admitting a client with a fractured extremity, the nurse should first assess...

area distal to fracture

Bone scan

assess for allergies to radioisotopes encourage fluids to distribute isotopes

Instructing a client who will have a total hip replacement tomorrow. What info is most important to teach?

assess the client's fears about the procedure

Radial/Ulnar Fracture with External Fixation

assess the pin sites serous drainage and mild drainage expected frequent finger exercises avoid lifting and twisting the arms osteomyletis

client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which p/o complication is the pt most at risk?

atelectasis/PNA

Nrs assesses VS of a Pt who had epidural anesthesia 4 hours ago. The nurse should assess first for:

bladder distention The last area to regain sensation is the perineal area, the nurse shld check the client for distended bladder. The client has received a large volume of IV fluids since the epidural and may not feel the urge to void/may be unable to void

When devo a teaching plan for a client who is prescirbed acetaminophen for muscle pain, which info shld the nurse expect to include?

can be used for ppl with aspirin allergy doesn't affect PLT aggregation causes little to no GI distress

Pt with NA has temp 102.6℉, is diaphoretic, and has productive cough. The pt is able to ambulate. What should the nrs do first?

change the bedsheets frequently

A male client underwent a lumbar spinal fusion yesterday. Which nursing assessment shld alert the nurse to the devo of possible complications?

clear, yellowish fluid on the dressing

Arthrography

contrast in joints - movement and x-rays to see tears in joints may feel discomfort/tingling may experience clicking/clacking in joints 24-48hrs after

Closed fracture

control edema and pain exercise to maintain unaffected muscles increased strength home safety

client in PACU with left BKA has pain in the left big toe, what should the nurse do first

give the client the prescribed opioid analgesics

Peak Flow Meter

green 80-100% yellow 50-80% red 0-50%

Ilizarov Fixation

halo fixation used for rotational changes

TPN is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything my mouth. The nurse should:

handle TPN using strict aseptic tech

Pt recovering from general anesthesia; pulse 150, bp 90/50, rr 28, temp 99.8℉, rigid muscles. The nrs determines that the pt is...

in the early stages of malignant hyperthermia and obtains emergency meds and notify the anesthesiologist

Nurse assesses a client for neurologic impairment after total hip replacement. Which findings indicate impairment in the affected extremity

inability to move

Nrs is assessing a Pt with COPD. Which requires immediate intervention?

inability to speak could indicate resp distress

A Pt had a mantoux test result of 8mm induration. The test is considered positive when the client...

is immunocompromised

Nrs admin theophylline to Pt. When evaluating the effectiveness of this med, the nrs shld assess the client for?

less difficulty breathing

Client with severe arterial occlusive dressing and gangrene of the left great toe. Which finding is expected

loss of hair on the lower leg

Following total hip replacement the nurse shld position the client by:

maintaining the extremity in slight abduction using an abduction splint or pillows placed between the thighs

MRI

may hear knocking sounds assess for contraindications assess for allergies for contrast testing

Assessing client's left leg for nv changes following total left knee replacement. Which are excepted normal findings?

moderate edema of left knee skin warm to touch cap refill <3 sec moves toes

Coumadin

monitor PT (11-13) and INR (1) inhibits vitamin K - extrinsic pathway

Heparin

monitor aPTT 25-35sec antidote: protamine sulfate intrinsic pathway

Disuse Syndrome

muscle atrophy and loss of strength tx: isometric exercises, muscle setting exercises

Pt has had an NG tube connected to low intermittent suction. The Pt is at risk for:

muscle cramping sign of hypokalemia

Signs of theophylline toxicity

nausea vomiting seizures insomnia

The nurse is preparing a client who has had a knee replacement with a metal joint to go home. What should the nurse instruct the Pt to do?

notify HCP abt joint prior to invasive procedure inform HCP prior to having MRI Notify airport security abt alarms

Nrs learns that a client who is shceduled for a tonsillectomy has been taking 40mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first?

notify the anesthesiologist of the prednisone admin

Fat Emboli

onset 12-72hr hyposemia, neuro compromise, petechial rash, tachycardia, crackles, wheeze, chest pain, cough, thick white sputum, h/a, agitation, fever>103 immediate immobilization, surgical fixation, minimal manipulation, support bone, fluid and lytes, high flow O2, PEEP steroid, vasopressor

Amputation meds

opioid beta blockers anti-seizures tricyclic antidepressant

Client with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse shld interpret these findings as the client may be experiencing

osteomyelitis

Tib/Fib w/cast

peroneal nerve palsy - foot drop toe exercise no weight for 7-10days partial weight for 6-10weeks

Client asks "Why will the HCP not tell me exactly how much of my leg he is going to take off?"

the adequacy of blood supply

Arthrocentesis

to collect synovial fluid remove hair from procedure site admin analgesics apply ice 24-48hr s/p

A Client with Pearson attachment on the traction setup. What is the purpose of this attachment?

to support the lower portion of the leg

Factors that attribute to amputation with peripheral vascular dx

uncontrolled DM for 15yr 20yr cigarette smoker serum cholesterol 275

to prevent complications associated with TPN admin thru a central line, the nurse should

use strict aseptic tech to change dressings secure all connections of the systems cover the insertion site with moisture-proof dressing

Arthroscopy

wrap joint with compression stocking to control swelling monitor neuro status

SCIP Measures

pre-op abx 1hr before incision DC abx within 24hr of surgery controlled 6am BGL <200 appropriate hair removal perioperative beta blocker VTE prophylaxis removal of cath POD 2 temp < 96.8 15 min after anesthetic end time

Open fracture

prevent infection osteomyletis and tetanus IV abx, external fixation wound irrigation and debridement

Cast syndrome

psych/physio affects claustophobic rxn anxiety, increased RR, HR, BP give pain and antianxiety meds

Which findings are significant data to gather from a client who has been dx with PA

quality of breath sounds occurrence of chest pain color of nail beds

Pt with grade III femur fracture in skeletal tractions. Intended outcome of traction?

reduce and immobilize the fracture

A client who has had a total hip replacement has a dislocated hop prosthesis. The nurse should first

stabilize the leg with Buck's traction

Nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which activity is least likely to be included in POC

personal hygiene with a complete bed bath

Client with posterolateral total hip replacement 2 days ago. What info would the nurse include in the client plan of care

position pillow between legs to maintain abduction allow client to be in supine position or lateral on noninjured side do not allow client to bend down to tie shoes place ice on incision site after physical therapy

Nrs is assessing a client with chronic emphysema. Which finding requires immediate intervention?

crackles ausculatated posteriorly halfway up the left lobe

Client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which activity should the nurse instruct the client to avoid?

crossing the legs while sitting down

A client is admitted to the PACU following left hip replacement. the VS: 96.6℉, pulse 90, RR 14, bp 128/80; only responds with moaning when speaking. What shld the nrs do first?

position the client on the right side unconscious pt placed on side immediately p/o to maintain an open airway and promote drainage of secretions.

Superior Mesenteric Artery Syndrome

decreased physical activity, decreased gastric motility increased intestinal gases and pressure -> N/V decreased blood supply to bowel --> gangrene

Compartment Syndrome

deep, throbbing pain (unrelenting), increased w/p-ROM 5P's wick catheter measures pressure in muscles normal 8mm Hg --> >30mmHg L2 decreased microcirculation bivalve cast, remove splint, maintain @heart level fasciotomy left open for 3-5hrs

Client with a left tibial fracture that required casting, 5 hours later client has increasing pain distal to the fracture despite morphine injection 30 min ago. Which area should be the nurse's next assessment?

distal pulses

Volkamann's Contractors

due to reduced arterial blood flow to the forearm unable to extend fingers decreased circulation needs to be addressed in 1-2hr or perm damage

which nursing intervention is most important to preventing p/o complications?

early ambulation