Chap. 62: Musculoskeletal Trauma and Orthopedic Surgery (Lewis)

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching?

a. "Check and clean the pin insertion sites daily." (Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.)

Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur?

a. Assess for hip pain. (Buck's traction is used to reduce painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.)

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery?

a. Assess the surgical site for hemorrhage. (The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.)

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?

a. Check the patient's prescribed weight-bearing status. (The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.)

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?

a. Notify the health care provider. (The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.)

What should the occupational health nurse advise a patient whose job involves many hours of typing?

a. Obtain a keyboard pad to support the wrist. (Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling.)

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

a. Reposition the patient every 1 to 2 hours. (Repositioning of orthopedic patients is within the scope of practice of UAP after they have been trained and evaluated in this skill. The other actions should be done by licensed nursing staff members.)

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective?

b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." (The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture.)

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching?

b. "You will begin work with a physical therapist tomorrow." (Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation.)

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first?

b. Administer prescribed PRN O2 at 4 L/min. (The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.)

The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take?

b. Administer prescribed analgesics. (Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment.)

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?

b. Administer prescribed pain medication. (The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.)

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury?

b. Apply an immobilizer to the affected leg. (A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee [McMurray's test].The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs [NSAIDs] are recommended for pain management.

The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time?

b. At least six weeks (Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.)

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?

b. Check the O2 saturation. (The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.)

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

b. Ensure the weight for the traction is hanging freely. (UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse)

Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible?

b. How and when to cut the immobilizing wires (The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.)

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching?

b. Monitored anesthesia care (The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned.)

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider?

b. Patient has been incontinent of urine and stool. (Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.)

After change-of-shift report, which patient should the nurse assess first?

b. Patient with repaired right femoral shaft fracture who reports tightness in the calf. (Calf swelling after a femoral shaft fracture suggests possible DVT or compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.)

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem?

b. Risk for infection (A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the problems caused by immobility are not as likely. Pain management is important, but the most important action is to prevent infection.)

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently?

b. The patient advances the left leg and both crutches together and then advances the right leg. (Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. If the 2- or 4-point gait is to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage.)

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast?

c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." (Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. The cast is typically removed in the outpatient setting. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.)

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery?

c. "I will be able to use my fingers with more flexibility to grasp things." (The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.)

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?

c. "Tell me what you know about your options for treatment." (The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion of the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state.)

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture?

c. Abdomen is distended, and bowel sounds are absent. (The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.)

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first?

c. Assess leg pulses and sensation. (The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.)

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care?

c. Assess the left axilla and change absorbent dressings as needed. (The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.)

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take?

c. Assess the pedal pulses. (The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.)

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures?

c. Buy shoes that provide good support and are comfortable to wear. (Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range-of-motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.)

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long-arm cast?

c. Call the health care provider for numbness of the hand. (Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.)

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider?

c. Capillary refill to the fingers is slow. (Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.)

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

c. Have the patient lift the back and buttocks using a trapeze. (The patient can lift the back slightly off the bed by using a trapeze. The patient may find it very difficult to turn to the side without assistance while in a fixator device. Delaying assessment and skin care may put the patient at risk for an undetected pressure injury. Pushing on the patient's hips may cause additional injury.)

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

c. Leaning over to pull on shoes and socks (Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.)

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider?

c. Slow capillary refill of the left foot (Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.)

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider?

c. The right arm appears shorter than the left. (A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.)

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first?

c. Use a cervical collar to stabilize the spine. (Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.)

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle?

c. Use pillows to elevate the ankle above the heart. (Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.)

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed?

d. "I can sleep in any position that is comfortable for me." (The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.)

A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching?

d. Modifying arm movements (Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.)

Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

d. Start progressive knee exercises to obtain 90-degree flexion. (After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Protected weight bearing is typically not ordered after this procedure.)

A patient has possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign?

d. Tingling in the right thumb and index finger (Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.)

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first?

d. Wrap the ankle and apply an ice pack. (Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.)