ATI PCCII Musculo Practice Questions

A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of what amputation procedures?

"Your pain will gradually become less severe." Rationale: Phantom leg pain usually diminishes over time, and often is intermittent in response to a trigger.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include what information in the teaching?

Buck's extension traction will relieve muscle spasms. Rationale: Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasms and trigger pain.

A nurse is assessing a client who has a cast in place for a fracture tibia. What action should the nurse take first?

Checking capillary refill. Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to check the client's capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury. Capillary refill provides data about the client's circulation.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has what type of fracture?

Comminuted. Rationale: With a comminuted fracture, the impact fragments the bone into several pieces.

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. What instructions should the nurse include in the teaching?

Dry the prosthesis sock completely before applying it to the limb. Rationale: The client should dry the prosthesis socket thoroughly with a clean cloth. Moisture between the socket and the stump can put the client at risk for fungal or bacterial infection and skin breakdown.

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago an is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed what complications?

Fat embolism. Rationale: The nurse should suspect that client has fat embolism syndrome. This complication develops within 24-48 hr of a fracture and can cause dyspnea, respiratory distress, alterations in mental status, tachycardia, and other manifestations. Older adults who have hip fractures are at greater risk.

A client who has a femur fracture states, "I can't stay in this bed any longer. I need to get home so I can take care of my family." The nurse responds, "You have talked about your family several times. Can you tell me more about your specific concerns?" What type of therapeutic communication response is the nurse using?

Focusing. Rationale: The open-ended statement is a means of focusing in on the problem and obtaining more information about the client's concerns. Focusing helps the nurse to zero in on a topic to identify the issues and concerns clearly.

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hr. What changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate from 18-44/min. Rationale: This change in respiratory rate is significant, as the first value is within expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances.

A nurse is assessing a client who has a left lower arm fracture. What findings indicate impaired venous return in the client's affected arm?

Increasing edema. Rationale: Increasing edema is a sign of impaired circulation. It is important for client who has a limb fracture to keep the limb elevated to reduce edema.

A nurse is planning care for a newly admitted client who has skeletal traction for a fracture femur. What interventions should the nurse include in the plan?

Monitor the client's pedal pulses every hour. Rationale: The nurse should assess the neuromuscular status of the client's affected extremity including assessing pulses, color, and capillary refill hourly for the first 24 hours following the placement of skeletal traction to prevent complications such as compartment syndrome or circulatory compromise.

A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. What finding should the nurse identify as a complication?

Pitting edema around the stump dressing. Rationale: If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.

A nurse is assessing a client who is postoperative following a right below-the-knee amputation. What findings should the nurse identify as a possible complication?

Presence edema above the stump dressing. Rationale: The nurse should recognize the stump dressing is used to prevent edema. Increased edema at the site can delay healing. The nurse should rewrap the stump and notify the provider.

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. What instructions should the nurse include in the teaching?

Report any worsening or unrelieved pain. Rationale: Pain can be a sign of complications such as compartment syndrome or skin breakdown. The client should report it to the provider.

A nurse in an urgent care center is caring for a client who has a greenstick fracture of the forearm. The nurse should explain that what injury has occurred with a greenstick fracture?

The bone is cracked lengthwise but did not break all the way through. Rationale: The nurse should explain that there is an incomplete break along the bone with a greenstick fracture.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. What explanations should the nurse provide?

This service began with the client's admission to the hospital. Rationale: Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of functioning. The process of rehabilitation begins with the client's admission to a health care facility for treatment.

A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that what nutrients is necessary for wound healing?

Vitamin C. Rationale: Vitamin C promotes collagen synthesis, which is essential for wound healing.

A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. What action should the nurse take?

Wrap the stump with an elastic bandage in a figure-eight configuration. Rationale: A figure-eight wrap helps prevent blood flow restriction and also helps shape and shrink the limb to prepare it for the prosthesis.

A nurse is caring for a client in the emergency room who had a traumatic amputation of his left arm in an industrial accident. The nurse should expect the client to be experiencing what stage of Kubler-Ross's stages of grief?

Denial. Rationale: Grief is the emotional reaction to loss. Although each individual experiences grief differently, the first stage is often denial. The client at this point has not yet come to terms with the fact that he has lost an extremity. He likely expects reattachment or may even perceive that his arm is still there.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. What is an appropriate nursing intervention for this client at this time?

Have the client lie prone every 3 hours for 20 minutes at a time. Rationale: The nurse should encourage the client to lie prone for 20-30 min every 3-4 hr to help prevent hip flexion contractures.

A nurse is caring for a client who has an unprepared femur fracture of the mid shaft. What techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes. Rationale: The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, what findings should the nurse expect to observe first?

Pallor of the toes. Rationale: If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.

A nurse is caring for a client who has a hip fracture that requires surgical repair. What health care professional is responsible for obtaining informed consent from the client for the procedure?

Surgeon. Rationale: The HCP who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent.

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. What action is the most important for the nurse to complete in the postoperative period?

Perform neuromuscular checks of the extremities. Rationale: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neuromuscular checks. These are a vital aspect of care for the client who has a sustained fracture and should be monitored every hour for the first 24 hour. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device is what occurs?

The client develops a life-threatening situation. Rationale: Traction weights, which are to hang freely at all times, are never removed without a specific provider prescription unless there is a life-threatening situation.

A nurse notes increasing edema in the calf of a patient who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of what complication?

Acute compartment syndrome. Rationale: Increasing edema is a manifestation of acute compartment syndrome, which is a complication that occurs when excessive pressure reduces circulation.