Neuro/Sensation

A nurse is assessing an infant with suspected developmental dysplasia of the hip. What does the nurse expect the infant's orthopedic status to reveal? 1. apparent shortening of one leg 2. limited ability to adduct the affected leg 3. narrowing of the perineum with an anal stricture 4. inability to palpate movement of the femoral head.

1. apparent shortening of one leg The affected leg appears to be shorter because the femoral head is displaced upward. The infant's ability to abduct, not adduct, the affected leg is affected. An anal stricture is not expected with developmental dysplasia of the hip. When the femoral head slips out of the acetabulum it is easily palpable.

An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment? 1. limited abduction of the affected hip 2. downward and inward rotation of the affected hip. 3. inability to flex and extend the hip on the affected side 4. free abduction of the affected hip when placed in the frog position

1. limited abduction of the affected hip Abduction of the hip is limited because the head of the femur slips out of the acetabulum and is unable to rotate. Rotation of the affected hip is unaffected in an infant with DDH. The hip can be flexed on the affected side. Free abduction of the affected hip is impossible; the frog position may be used in the treatment of DDH.

A client returns from surgery after a right below-the-knee amputation with the residual limb elevated on a pillow to prevent edema. In which position should the nurse place the client after the first postoperative day? 1. with the residual limb immobilized 2. for short periods in the prone position 3. for short periods in the right side-lying position 4. with the residual limb elevated for a total of three days

2. for short periods in the prone position Positioning the client in the prone position for short periods helps prevent hip flexion contractures. The client's residual limb should not be immobilized. Exercises to prevent contractures are begun as soon as possible. Positioning the client in the right side-lying position can cause trauma to the incision site and should be avoided. The client's residual limb should not be elevated for more than 48 hours because hip flexion contractures can result.

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of: 1. tactile illusions associated with severed blood vessels. 2. nerve ending in the limb that are still intact and react to stimuli 3. an unconscious phenomenon to aid with grieving over the lost body part. 4. hallucinations secondary to emotional symptoms associated with the distress of amputation.

2. nerve endings in the limb that are still intact and react to stimuli. The neural endings that innervated the limb are still intact and may be stimulated (e.g., touch, environmental temperature, barometric pressure changes) within the residual limb. Severed blood vessels are not involved in phantom limb sensation. Although an individual must grieve over a lost body part, the grieving is unrelated to phantom limb sensation. Although phantom limb sensation is a hallucinatory-type experience, it is not part of a psychotic process.

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? Select all that apply. 1. resume usual activities 2. report swelling of fingers 3. keep the affected shoulder immobilized 4. elevate casted arm when the child is standing. 5. lower the casted arm when the child is lying down.

2. report swelling of fingers. 4. elevate casted arm when the child is standing When swelling of the fingers occurs, the cast may become too tight, resulting in neurovascular damage; permanent damage can occur in 6 to 8 hours. The casted arm should be in a sling when the child is upright to promote venous return. Rest with elevation of the extremity is recommended; strenuous activity should be avoided for several days. Joints above and below the cast should be moved to maintain flexibility. The casted arm should be elevated when the child is resting to promote venous return.

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures? 1. mobility will be delayed if correction is postponed. 2. traction is effective if it is used before toddlerhood. 3. infants are easier to manage in spica casts than are toddlers. 4. infants' cartilaginous hip joints promote molding of the acetabulum.

4. infants' cartilaginous hip joints promote molding of the acetabulum The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment.

A client with osteomyelitis is receiving antibiotic therapy via a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. The nurse concludes that this finding probably indicates that: 1. the does should be increased 2. the does is in excess of the clients needs 3. there was an adequate administration of the antibiotic 4. there was a problem with the obtaining of the blood specimens

4. there was a problem with the obtaining the blood specimens. Peak levels will always be higher than trough levels; therefore, it indicates some mix-up in the drawn samples. Increasing the dose is an appropriate action if the trough level were too low. Providing a dose in excess of the client's needs is an appropriate action if the trough level were too high, but not exceeding the peak. There is not enough information to determine if the antibiotic administered is adequate.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: 1. addressing the pain 2. reversing feelings of hopelessness 3. promoting mobility in the residual limb 4. acknowledging the grieving for the lost limb.

1. addressing the pain Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

After an open reduction and internal fixation of a fractured hip, what assessments of the client's affected leg should the nurse make? Select all that apply. 1. skin temperature 2. mobility of the hip 3. sensation in the toes 4. condition of the pins 5. presence of pedal pulse

1. skin temperature 3. sensation in the toes 5. presence of pedal pulse Increased skin temperature may indicate the presence of an infection; decreased skin temperature suggests impaired circulation. Sensation in the toes assesses the neural integrity distal to the surgical site. Presence of pedal pulse assesses the circulatory integrity distal to the surgical site. Flexion and abduction of the hip are contraindicated because they may dislodge the head of the femur from the acetabulum. No external pins are present with an internal fixation.

A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond? 1. "tuck a folded diaper above the perineal opening." 2. "place plastic wrap or duct tape around the perineal edges of the cast." 3. "wipe the cast with a wet cloth and sprinkle it with baby powder." 4. "do the best you can, because it will get soiled no matter what you do."

2. "place plastic wrap or duct tape around the perineal edges of the cast." Suggesting the use of a protective nonabsorbent material is supportive, constructive, practical, and factual. Placing a diaper above the perineal area will not protect the area beneath the perineum. Although water may or may not cause dissolution of cast material, the infant may inhale powder, which can cause respiratory difficulties. "Do the best you can" is a negative response that provides neither a suggestion nor support to the mother.

When preparing a client for discharge after a laminectomy, the nurse evaluates that further health teaching is necessary when the client says, "I should: 1. sleep on a firm mattress to support my back" 2. spend most of the day sitting in a straight-back chair" 3. put a pillow under my legs when sleeping on my back" 4. avoid lifting heavy objects until the health care provider tells me I can."

2. spend most of the day sitting in a straight-back chair." Maintaining the sitting position for a prolonged period places excessive stress on the surgical area. Sleeping on a firm mattress to support the back maintains appropriate lordosis of the small of the back and provides support. Putting a pillow under the legs when sleeping on one's back relieves pressure on the back and promotes comfort in bed. Avoiding lifting heavy objects until the health care provider's approval prevents excessive pressure on the musculature and vertebral column.

A client who has experienced a fracture of the femur is experiencing respiratory difficulties, and the nurse suspects a pulmonary embolus. Which of these assessment findings is specific to a fat embolism? 1. chest pain 2. dyspnea 3. petechiae 4. decreased SaO2

3. Petechiae Petechiae on the chest and shoulders suggest fat emboli after fractures. The petechial rash occurs from occlusion of small dermal capillaries, leading to extravasation of red blood cells. Both a fat embolism and a blood clot embolism in the lungs may cause symptoms, such as altered mental status, chest pain, dyspnea, decreased SaO2, and increased respirations and pulse.

A 14-year-old girl in whom scoliosis has been diagnosed undergoes spinal fusion. On the first postoperative day her face is red, she is rigid, and she is crying because she is in pain. She has prescriptions for morphine sulfate for severe pain and an acetaminophen-codeine compound for moderate pain. What information should influence the nurse's choice of analgesic? 1. one does of morphine may be given, but the drug should be restricted thereafter because it is addictive 2. adolescents tend to exaggerate their discomfort, particularly when they are immobilized by surgery or injury. 3. spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. 4. the acetaminophen-codeine compound is preferred because morphine can cause respiratory depression or respiratory arrest.

3. Spinal fusion causes considerable pain during the early postoperative days, and morphine is the more effective analgesic. Spinal fusion causes considerable pain for several days and requires a strong analgesic. The first postoperative day is too early to begin weaning the client from opiates. Adolescents are no more prone to exaggerating their discomfort than clients in any other age group. A more potent analgesic, such as morphine, is needed, and the prescribed dosage should not cause respiratory problems.

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1. remove the weights from the traction every 2 hours to promote comfort. 2. turn the client from side to side every 2 hours to prevent pressure on the coccyx. 3. raise the knee gatch on the bed every 2 hours to limit the shearing force of traction 4. assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.

4. Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion. Arterial perfusion and the presence of hemorrhage must be assessed at least every 2 hours to prevent complications or to identify problems early. Removing the weights will interfere with the pull of traction. Turning the client from side to side will interfere with the pull of traction. Raising the knee gatch on the bed will interfere with the pull of traction.

A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign? 1. unilateral droop of the hip 2. broadening of the perineum 3. apparent shortening of one leg 4. audible click on hip manipulation

4. audible click on hip manipulation With specific manipulation an audible click may be heard as the femoral head slips into the acetabulum; this is known as the Ortolani sign. Unilateral droop of the hip is the Trendelenburg sign; it is associated with weight-bearing. Broadening of the perineum is associated with bilateral dislocation. Apparent shortening of one leg is the Allis sign.

During the initial assessment of a 7-year-old child with a compound fracture of the wrist the nurse identifies a dark, wet area on the cast. What is the nurse's next action? 1. notifying the practitioner about the stain 2. removing the stain, using soap and water 3. asking whether the child was playing with a colored pen 4. circling the area with a pen, noting the date and the time

4. circling the area with a pen, noting the date and the time The dark stain indicates bleeding. By circling the area the nurse can determine that more bleeding has occurred if the stained area spreads past the baseline assessment. It is too soon to report the stain; a compound fracture may bleed initially, and the site should be monitored frequently. A compound fracture may bleed initially, and the site should continue to be monitored. If the stain extends beyond the initial stain, the practitioner should be notified. Trying to remove the stain is inappropriate. The blood is coming from inside the cast and will be impossible to remove. The professional nurse should understand that the stain is blood, not ink.

A back brace is prescribed for a client who had a laminectomy. What instruction should the nurse include in the teaching plan? 1. apply the brace before getting out of bed 2. put the brace on while in the sitting position 3. use the brace when the back begins to feel tired 4. wear the brace when performing twisting exercises.

1. apply the brace before getting out of bed Appling the brace before getting out of bed is done while in the supine position before the body is subjected to the force of gravity in a vertical position. Anatomical landmarks are easier to locate for correct application of the brace, and intraabdominal organs have not shifted toward the pelvic floor by gravity. The brace should be applied while in the supine position, not the sitting position. The brace should be worn as prescribed, not just when the client feels tired. Twisting exercises are contraindicated because they exert excessive pressure on the operative site.

A client is admitted with cellulitis of the left leg and a temperature of 103° F. The primary health care provider prescribes intravenous (IV) antibiotics. Before instituting this therapy, the nurse should: 1. determine the clients allergies 2. apply a warm, moist dressing over the cellulitis. 3. measure the amount of swelling in the clients left leg 4. obtain the results of the culture and sensitivity

1. determine the clients allergies Drug hypersensitivity and anaphylaxis are most common with antimicrobial agents. Applying a warm, moist dressing over the area is a dependent function; it is not crucial to starting antibiotic therapy. Measuring the amount of swelling in the client's leg is an important assessment, but it is not crucial to starting antibiotic therapy. Withholding treatment until culture results are available may extend the infection.

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic? 1. encouraging her peers to visit 2. keeping her lower body covered 3. placing her in a room by herself 4. limiting her visitors to the family.

1. encouraging her peers to visit. Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers as well as family.

The care plan for a client with a fractured hip includes nursing actions to prevent which type of contracture? 1. flexion of the hip 2. abduction of the hip 3. hyperextension of the hip 4. internal rotation of the hip

1. flexion of the hip After a fractured hip, the muscle spasms and the client's tendency to flex the hips can lead to flexion contractures of the hip. Abduction contractures do not occur; abduction is maintained if a prosthesis is used to keep the head of the femur in the acetabulum. Contractures most often involve flexor, not extensor, muscles. The hip will tend to externally rotate.

The nurse is preparing to ambulate a client following the client's above-the-knee amputation of the left leg. The nurse should provide which instructions to the client? 1. keep the left hip in extension and alignment 2. keep the left hip raised with the residual limb elevated 3. lift the left shoulder and left hip when taking a step 4. use the prescribed crutches until the residual limb is healed completely

1. keep the left hip in extension and alignment. Keeping the hip in extension and alignment offsets the development of hip deformities resulting from contractures. It also maintains the correct center of gravity when the client is upright. Keeping the hip raised with the residual limb elevated promotes flexion contracture of the hip. Lifting the shoulder and hip of the affected side when taking a step may alter the center of gravity and cause a loss of balance. A prosthesis may be applied early in the postoperative period but requires a rigid dressing (cast) to prevent edema; ambulation can be facilitated by the use of a walker, crutches, parallel bars, or a cane.

Spinal fusion is performed in an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? 1. log-rolling every 2 hours 2. checking the dressing frequently 3. supervising deep-breathing exercises 4. maintaining the adolescent in the supine position for 3 days

1. log-rolling every 2 hours Log-rolling is necessary to prevent movement of the newly aligned and instrumented vertebrae and should be done frequently to prevent skin breakdown. Dressings are checked frequently in all postoperative clients; this action is nonspecific. Coughing and deep-breathing are done by most postoperative clients; this action is nonspecific. The client who has had a spinal fusion may be turned and still be protected from injury with log-rolling. Remaining in one position for 3 days could lead to skin breakdown from unrelieved pressure.

X-ray films reveal that a client has closed fractures of the right femur and tibia. In addition, multiple soft-tissue contusions are present. What is the most important nursing intervention? 1. perform a neurovascular assessment of the extremity. 2. reassure the client that these injuries are not that serious 3. gather equipment needed for the application skeletal traction 4. prepare the client for a surgical reduction of injured extremity.

1. perform a neurovscular assessment of the extremity. Identifying the status of the damage is the priority. Before a treatment protocol is determined, the presence of nerve or vascular damage and compartment syndrome must be identified. False reassurance is never appropriate. Skeletal traction is used rarely. Closed fractures in the absence of soft tissue damage generally are reduced by manipulation. Closed fractures with soft tissue damage may require an external fixation device to reduce the fracture, immobilize the bone, and allow for treatment of the soft tissue damage. Preparing the client for surgery is premature; more data are necessary before a treatment option is determined.

A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular assessment cannot be performed while the cast is in place? 1. pulse 2. color 3. warmth 4. blanching

1. pulse The pedal pulse cannot be palpated under a boot cast. Assessments of the color, warmth, and blanching of the toes are all appropriate neurovascular checks.

A nurse is assessing an 18-month-old toddler with suspected developmental dysplasia of the left hip. In what position should the nurse place the toddler to elicit the Trendelenburg sign? 1. standing on the affected leg 2. supine with the back arched 3. side-lying on the unaffected side 4. sitting upright with the legs separated

1. standing on the affected leg When the child is standing and bearing weight on the affected hip, the pelvis tilts downward instead of upward—the Trendelenburg sign. The supine, side-lying, and sitting positions do not accomplish the desired effect because weight bearing is needed to tilt the pelvis.

The nurse is reviewing a plan of care for a client who has experienced a traumatic amputation of a leg. The nurse recognizes that which intervention listed on the plan is of lowest priority? 1. teaching residual limb care 2. monitoring hemoglobin levels 3. maintaining the compression dressing 4. using therapeutic interviewing techniques

1. teaching residual limb care Teaching residual limb care is not a priority at this point. The client is too traumatized to learn. It will assume priority as the client's recovery progresses. The nurse must closely monitor the hemoglobin level because blood loss is a major problem. Maintaining a pressure dressing helps to prevent edema and bleeding and helps to shape the residual limb for a prosthesis. The client has experienced a major life event; the nurse will need to be empathetic and use interviewing skills to encourage expression of feelings.

A client is going for a magnetic resonance imaging (MRI). Before taking the client to the procedure the nurse should ascertain: 1. scheduled medications that have been given 2. all metal, such as jewelry and hair ornaments, has been removed. 3. adequate prehydration has been given 4. the client has emptied the bladder.

2. all metal, such as jewelry and hair ornaments, has been removed. All metal must be removed because the MRI emits a strong magnetic field. All medications may not be necessary before the test. Being hydrated is not needed and may cause interruptions for client to void. The client should have the opportunity to void before going for the test as a convenience.

A back brace is prescribed for a client who had a laminectomy. What should the nurse include in the client's teaching plan? 1. use the brace when the back feels tired. 2. apply the brace before getting out of bed. 3. put the brace on while in the sitting position. 4. wear the brace when performing twisting exercises.

2. apply the brace before getting out of bed. Applying the brace before getting out of bed is done while in the supine position before the body is subjected to the force of gravity in the vertical position; anatomic landmarks are easier to locate for correct application of the brace, and intraabdominal organs have not shifted toward the pelvic floor via gravity. Using the brace when the back feels tired is unsafe; it should be worn the entire day for support. Putting the brace on while in the sitting position will result in inaccurate application of the brace. Twisting exercises are contraindicated because they exert excessive pressure on the operative site.

A 3-year-old is placed in a bilateral hip spica cast for the treatment of developmental dysplasia of the hip. The nurse should teach the parents to monitor their child and report to the practitioner the occurrence of: 1. warm toes 2. leg numbness 3. skin desquamation 4. generalized discomfort

2. leg numbness Numbness is a neurological symptom that should be reported immediately because it indicates pressure on the nerves and blood vessels. Warm toes indicate intact circulation to the lower extremities. Peeling skin is the result of inadequate skin care but can be managed easily with lotion or oil. Some degree of discomfort is expected after cast application.

What should the nurse include in the plan of care for a client who just had a posterior lumbar laminectomy? 1. encourage the client to cough. 2. reposition the client by log rolling 3. assess the client for indication of peritonitis 4. instruct the client to bend the knees when turning

2. reposition the client by log rolling. Log-rolling maintains the alignment of the vertebral column. Coughing will increase the pressure of the cerebrospinal fluid (CSF) surrounding the spinal cord and intensify the pain; incentive spirometry and turning should be used to prevent respiratory complications. Peritonitis is not a danger because the abdominal cavity was not opened. Flexion of the knees is avoided postoperatively because it alters intervertebral pressure.

A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, the nurse expects the client's postoperative plan of care to include: 1. routinely turning the client from side to side 2. sequential compression stockings 3. isometric exercises to the extremities 4. passive range of motion (ROM) to the affected extremity.

2. sequential compression stockings. Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates; this promotes venous return and prevents venous stasis and thromboembolism. Turning on the operative side is contraindicated because it places tension on the hip joint and may traumatize the incision. Isometric exercises may be prescribed to promote muscle strength; however, preventing the major complication, thromboembolism, is the priority. Passive ROM is contraindicated immediately after surgery.

A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? 1. femoral pulse 2. toes for mobility 3. condition of the pin 4. range of motion of the knee

2. toes for mobility Monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this is part of a neurovascular assessment. The femoral artery is not assessed because it is not distal to the surgical site. No pin is present with an open reduction and internal fixation of a fractured hip. A range of motion of the knee assessment may cause flexion of the hip, which is contraindicated.

A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. What goal is a priority for the nurse planning care for this client? 1. identifying personal strengths 2. controlling impulsive behaviors 3. correcting electrolyte imbalances 4. developing a contract for treatment goals.

3. correcting electrolyte imbalances Electrolyte imbalances can precipitate life-threatening dysrhythmias. Although clients with the diagnosis of anorexia nervosa have low self-esteem and identifying and supporting strengths promote the development of a positive self-regard, this is not the priority at this time. Clients with anorexia are perfectionists who usually do not display impulsivity. Developing a contract for treatment goals is difficult to accomplish initially because anorexic clients often deny the illness and evade therapeutic treatment.

A 3-month-old infant with developmental dysplasia of the hip (DDH) is placed in a Pavlik harness. The home care nurse sees the infant sleeping without the harness. When asked about this, the mother explains that her baby will not sleep with the harness on. How should the nurse respond? 1. assure her that the harness may be removed for a short nap 2. encourage her to reapply the harness after her baby falls asleep 3. explain to her the importance of wearing the harness continuously 4. instruct her to eliminate one of the infant's daily naps, thereby reducing the time spent out of the harness.

3. explain to her the importance of wearing the harness continuously For an optimal outcome the harness should be worn continuously; some practitioners permit its removal for bathing. Application of the harness will probably awaken the sleeping infant. Naps should not be limited.

The nurse enters a client's room and finds the client on the floor crying for help. It is obvious to the nurse that the client has sustained a hip fracture. Which action should the nurse take next? 1. administer pain medication 2. place the affected extremity in traction 3. immobilize the affected extremity 4. notify the health care provider on call

3. immobilize the affected extremity The nurse should immobilize the affected extremity first. Further damage and internal bleeding could occur if the extremity is not immobilized. Clients do experience pain with a hip fracture and will require pain medication; however, the emergency management for a fractured hip is to immobilize the extremity. The nurse will need to notify the client's health care provider first.

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. presence of posterior tibial pulses 2. mobility of the knees when flexed 3. warmth of the toes of both feet 4. alignment of legs on x-ray

3. warmth of the toes of both feet Peripheral vascular assessment includes comparing temperature, color, sensation, mobility, capillary refill, and if accessible, peripheral pulses. The posterior tibial pulse site is under the cast and is not accessible for palpation. Mobility of the knees when flexed is impossible because the cast extends from the thigh to just above the toes. X-rays permit assessment of bones, not of circulation.

The nurse is preparing to initiate intravenous antibiotic therapy on a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intravenous antibiotics, which task should the nurse ensure has been completed? 1. red blood cell count 2. urinalysis 3. wound culture 4. knee exray

3. wound culture A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first, and then after the organism has been identified an organism specific antibiotic can be given. There is no indication that a red blood cell count is needed; however, a white blood cell count would be beneficial. A urinalysis is not needed as data gathered during the assessment indicate an incisional infection. At the early stage of the infection, there is not a need to obtain a knee x-ray.

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains the purpose is to: 1. limit the formation of blood clots 2. decrease the phantom limb sensation 3. prevent hemorrhage and cover the incision 4. support the soft tissue and minimize swelling.

4. support the soft tissue and minimize swelling. Pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb. Although it may limit clot formation, its primary purpose is to promote venous return, prevent edema, and shrink the distal part of the residual limb. Bandaging does not decrease the occurrence of phantom limb sensation. Although pressure may prevent hemorrhage, its primary purpose is to prevent edema and shrink the distal part of the residual limb.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? 1. fever and chest pain 2. positive homans' sign 3. loss of sensation in the operative leg 4. tachycardia and petechiae over the chest

4. tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans' sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurological dysfunction; it is not an indication of a fat embolism

The nurse is caring for an elderly client who has a right hip fracture. What intervention should be included in the plan of care? 1. nutrition supplements 2. cardiac monitoring 3. oxygen therapy 4. venous thromboembolism prevention (VTE)

4. venous thromboembolism prevention (VTE) VTE causes most fatalities in elderly clients with hip fractures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all.