acute #3 - ch 41

A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites. B) Encourage the patient to push up with the elbows when repositioning. C)Encourage the patient to perform isometric exercises once a shift. D) Assess the pin insertion site every 8 hours.

D) Assess the pin insertion site every 8 hours.

A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurses choice of interventions? A) Improving the patients level of function B) Helping the patient come to terms with limitations C) Administering medications safely D) Improving the patients adherence to treatment

A) Improving the patients level of function

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russells traction B) Dunlops traction C) Bucks extension traction D) Cervical head halter

C) Bucks extension traction

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patients lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf

A) Increased warmth of the calf

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be braced by the footboard of the bed. D) Skeletal traction may be removed for brief periods to facilitate the patients independence.

A) Knots in the rope should not be resting against pulleys.

7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A) Make sure you dont bring your knees close together. B) Try to lie as still as possible for the first few days. C) Try to avoid bending your knees until next week. D) Keep your legs higher than your chest whenever you can.

A) Make sure you dont bring your knees close together.

A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury? A) Numbness and burning of the foot B) Pallor to the dorsal surface of the foot C) Visible cyanosis in the toes D) Inadequate capillary refill to the toes

A) Numbness and burning of the foot

2.A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication? A) Obstructed arterial blood flow to the forearm and hand B) Simultaneous pressure on the ulnar and radial nerves C) Irritation of Merkel cells in the patients skin surfaces D) Uncontrolled muscle spasms in the patients forearm

A) Obstructed arterial blood flow to the forearm and hand

A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. A) Preventing additional injury B) Immobilizing prior to surgery C) Providing support D) Controlling movement E) Promoting bone remodeling

A) Preventing additional injury C) Providing support D) Controlling movement

A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patients care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses? A) Risk for Impaired Skin Integrity B) Risk for Falls C) Risk for Imbalanced Fluid Volume D) Risk for Aspiration

A) Risk for Impaired Skin Integrity

The nurse is helping to set up Bucks traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift

A) Within 30 minutes, then every 1 to 2 hours

5. A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A)Keep the patients hips in abduction at all times. B)Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowlers. D) Seat the patient in a low chair as soon as possible.

A)Keep the patients hips in abduction at all times.

A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises

B) Application of a cast

A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action? A) Taking an opioid analgesic as ordered B) Applying a cold pack to the injured site C) Performing passive ROM exercises D) Applying a heating pad to the affected muscle

B) Applying a cold pack to the injured site

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurses best action? A) Administer pain medication as ordered. B) Assess the surgical site and the affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Assess the patient for signs and symptoms of systemic infection.

B) Assess the surgical site and the affected extremity.

The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction? A) Balanced traction can be applied at night and removed during the day. B) Balanced traction allows for greater patient movement and independence than other forms of traction. C) Balanced traction is portable and may accompany the patients movements. D) Balanced traction facilitates bone remodeling in as little as 4 days.

B) Balanced traction allows for greater patient movement and independence than other forms of traction.

A nurse is reviewing a patients activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position

B) Bending down to put on socks

A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? A) Inform the primary care provider promptly. B) Document this as an expected assessment finding. C) Limit the patients fluid intake to 2 liters for the next 24 hours. D) Administer a loop diuretic as ordered.

B) Document this as an expected assessment finding.

A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patients affected limb are spastic. How does this change in muscle tone affect the patients traction prescription? A) Traction must temporarily be aligned in a slightly different direction. B) Extra weight is needed initially to keep the limb in proper alignment. C) A lighter weight should be initially used. D) Weight will temporarily alternate between heavier and lighter weights.

B) Extra weight is needed initially to keep the limb in proper alignment.

A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patients cast care? A) Cover the cast with a blanket until the cast dries. B) Keep your right leg elevated above heart level. C) Use a clean object to scratch itches inside the cast. D) A foul smell from the cast is normal after the first few days.

B) Keep your right leg elevated above heart level.

A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip.

B) Patient is able to perform transfers safely.

While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient? A) Risk for Infection B) Risk for Peripheral Neurovascular Dysfunction C) Unilateral Neglect D) Disturbed Kinesthetic Sensory Perception

B) Risk for Peripheral Neurovascular Dysfunction

mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed. B) Teach the patient to perform deep breathing and coughing exercises. C) Administer prophylactic antibiotics as ordered. D) Administer nebulized bronchodilators and corticosteroids as ordered.

B) Teach the patient to perform deep breathing and coughing exercises.

A nurse is assessing a patient who is receiving traction. The nurses assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A) The leg that was assessed is free from DVT. B) The patients tibial nerve is functional. C) Circulation to the distal extremity is adequate. D) The patient does not have peripheral neurovascular dysfunction.

B) The patients tibial nerve is functional.

A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance. B) The physical therapist will likely help you get up using a walker the day after your surgery. C) Our goal will actually be to have you walking normally within 5 days of your surgery. D) For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs.

B) The physical therapist will likely help you get up using a walker the day after your surgery.

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome

C) Compartment syndrome

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.

C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.

The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. D) Keep the hip flexed by placing pillows under the patients knee.

C) Protect the affected leg from internal rotation.

An elderly patients hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurses priority assessment? A) The presence of leg shortening B) The patients complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation

C) Signs of neurovascular compromise

The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk? A) Encourage independence with ADLs whenever possible. B) Monitor the patients nutritional status closely. C) Teach the patient to perform ankle and foot exercises within the limitations of traction. D) Administer clopidogrel (Plavix) as ordered.

C) Teach the patient to perform ankle and foot exercises within the limitations of traction.

A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions? A) Shifting ones weight in bed B) Bearing down while having a bowel movement C) Turning from side to side D) Coughing without splinting

C) Turning from side to side

A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patients plan of care. What intervention is most justified in the care of this patient? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge

C) Use of a pressure-relieving mattress

A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Use of a cardiopulmonary bypass machine B) Postoperative blood salvage C) Prophylactic blood transfusion D) Autologous blood donation

D) Autologous blood donation

A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patients statements would indicate to the nurse that the patient requires further teaching? A) Ill need to keep several pillows between my legs at night. B) I need to remember not to cross my legs. Its such a habit. C) The occupational therapist is showing me how to use a sock puller to help me get dressed. D) I will need my husband to assist me in getting off the low toilet seat at home.

D) I will need my husband to assist me in getting off the low toilet seat at home.

A nurse is emptying an orthopedic surgery patients closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurses best action? A) Aspirate a small amount of drainage for culturing. B) Advance the drain 1 to 1.5 cm. C) Irrigate the drain with normal saline. D) Inform the surgeon of this finding.

D) Inform the surgeon of this finding.

A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords. B) Release the weights and replace them immediately after positioning. C) Reposition the bed instead of repositioning the patient. D) Maintain consistent traction tension while repositioning.

D) Maintain consistent traction tension while repositioning.

A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication? A) Cellulitis B) Septic arthritis C) Sepsis D) Osteomyelitis

D) Osteomyelitis

A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patients dorsalis pedis or posterior tibial pulse and the patients foot is pale. What is the nurses most appropriate action? A) Warm the patients foot and determine whether circulation improves. B) Reposition the patient with the affected foot dependent. C) Reassess the patients neurovascular status in 15 minutes. D) Promptly inform the primary care provider.

D) Promptly inform the primary care provider.

A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as ordered C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation

D) Reporting signs of impaired circulation

1.A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the patient gets home. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.

D) The cast will only have full strength when dry.