Final Review

The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "globs" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea and altered mental status. 2. Obtain an arterial blood gas and order a portable chest x-ray. 3. Call the HCP for a ventilation/perfusion scan. 4. Instruct the UAP keep the client on strict bedrest.

1. The nurse should assess the client for signs of hypoxia from a fat embolism, which is what the nurse should anticipate from "globs" in the urine.

The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. Related to hypovolemia and myoglobin release b. Related to fluid overload and peripheral edema c. Related to prolonged resuscitation and hypoxia d. Related to direct blunt trauma to the kidneys

A

To prevent the complication of Curling's ulcer, what does the nurse anticipate? A. NG tube insertion B. H2 histamine blockers C. q4 hour abdominal assessment D. systemic antibiotic

B

A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? A. Sit in a chair for 1 to 2 hours three times each day B. Dangle the residual limb for 20 to 30 minutes every 6 hours. C. Lie prone with hip extended for 30 minutes four times per day. D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

C. To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A. Administer enoxaparin (Lovenox). B. Provide range-of-motion exercises. C. Apply sequential compression boots. D. Immobilize the fracture preoperatively.

D. The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A. "No one is available to assist and accompany the patient." B. "The cast is not dry yet, and it may be damaged while using crutches." C. "Rest, ice, compression, and elevation are in process to decrease pain." D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D. For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) a) Excruciating pain b) Capillary refill less than 3 seconds c) Decreased sensory function d) Loss of motion e) 2+ peripheral pulses in the affected distal pulse

a) Excruciating pain c) Decreased sensory function d) Loss of motion Explanation: Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately. pg.1107

The client with a newly applied cast complains of severe unrelenting pain. Which of the following nursing actions should the nurse do next? a) Make the client NPO and notify the physician. b) Loosen the edges of the cast and elevate the leg. c) Reposition the extremity for comfort and apply ice. d) Administer a dose of morphine sulfate.

a) Make the client NPO and notify the physician. Explanation: The client is exhibiting symptoms of compartment syndrome. The physician needs to be contacted as treatment options include bivalving of the cast or a possible fasciotomy, a surgical procedure. pg.1107

A nurse is giving instructions to a client who's going home with a cast on his leg. Which teaching point is most critical? a) Reporting signs of impaired circulation b) Exercising joints above and below the cast, as ordered c) Using crutches properly d) Avoiding walking on a leg cast without the physician's permission

a) Reporting signs of impaired circulation Explanation: Although all of these points are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the physician orders. The client should be told not to walk on the cast without the physician's permission. pg.1109

Which action would be most important postoperatively for a client who has had a knee or hip replacement? a) Encouraging expressions of anxiety. b) Assisting in early ambulation. c) Using a continuous passive motion (CPM) machine. d) Providing crutches to the client.

b) Assisting in early ambulation. Explanation: An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement. A CPM machine or crutches may be provided when prescribed. It is important to encourage clients to express their feelings of anxiety or depression. This is more crucial for clients who undergo an amputation rather than for clients who undergo a replacement surgery. pg.1128

Mr. Williams returned to the nursing unit following orthopedic surgery and is complaining of pain. Which of the following interventions will help relieve pain? a) Encourage client to do ROM exercises as indicated. b) Elevate the affected extremity and use cold applications. c) Apply antiembolism stockings as indicated. d) Instruct client to deep breathe and cough every 2 hours until he can ambulate.

b) Elevate the affected extremity and use cold applications. Explanation: Elevating the affected extremity and using cold applications reduce swelling. This intervention helps with maintenance of effective respiratory rate and depth. This intervention helps maintain full ROM of unaffected joints. They help prevent deep vein thrombosis (DVT). pg.1105

A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply. a) Surgery will not be required. b) The bones of the left leg will be aligned. c) Muscle spasms will be relieved. d) Less pain medication will be required. e) Immobilization of the left leg will be maintained.

b) The bones of the left leg will be aligned. c) Muscle spasms will be relieved. e) Immobilization of the left leg will be maintained. Explanation: Traction is used to relieve muscle spasm, align bones, and maintain immobilization when used properly. It will not replace surgery to correct the fracture. The client will still require pain medication prior to surgical correction. pg.1111

A nurse is caring for a client who recently underwent a total hip replacement. The nurse should: a) ease the client onto a low toilet seat. b) limit hip flexion of the client's hip when he sits. c) use soft chairs when the client is sitting out of bed. d) allow the client's legs to be crossed at the knees when out of bed.

b) limit hip flexion of the client's hip when he sits. Explanation: The nurse should instruct the client to limit hip flexion to 90 degrees when he sits. The nurse should supply an elevated toilet seat so that the client can sit without having to flex his hip more than 90 degrees. The nurse should instruct the client not to cross his legs to avoid dislodging or dislocating the prosthesis. The nurse should caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable. pg.1119

A nurse is caring for a client with a cast on his left arm after sustaining a fracture. Which assessment finding is most significant for this client? a) Minimal pain in the left arm b) Cast edges are rough, with skin irritation present c) Fingers on the left hand are swollen and cool d) Presence of a normal popliteal pulse

c) Fingers on the left hand are swollen and cool Explanation: Swollen and cool fingers on the left hand are the most significant assessment findings. They represent altered circulation to the hand caused by the cast. A normal radial, not popliteal, pulse should be present in the left arm; the popliteal pulse is found on the leg. Skin irritation is an abnormal assessment finding but it isn't as significant as altered circulation. Minimal pain in the left arm is expected. pg.1109

Which action by the nurse would be inappropriate for the client following casting? a) Circulate room air with a portable fan. b) Petal and smooth the edges of the cast. c) Protect the cast by covering with a sheet. d) Handle the cast with the palms of hands.

c) Protect the cast by covering with a sheet. Explanation: The nurse performs actions to facilitate drying of the cast. The cast should be exposed to air. Portable fans can be used to dry the cast. Pressure on the cast should be avoided. pg.1104

Which of the following statements describes external fixation? a) The bone is surgically exposed and realigned. b) The surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. c) The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. d) The bone is restored to its normal position by external manipulation.

c) The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. Explanation: In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned. pg.1110

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? a) Ensuring that the weights hang free at all times b) Keeping the client from sliding to the foot of the bed c) Keeping the ropes over the center of the pulley d) Assessing the extremity for neurovascular integrity

d) Assessing the extremity for neurovascular integrity Explanation: Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free. pg.1114

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority? a) Monitoring the client for skin breakdown b) Supporting the traction weights with a chair or table to prevent accidental slippage c) Restricting the client's fluid and fiber intake to reduce the movement required for bedpan use d) Maintaining traction continuously to ensure its effectiveness

d) Maintaining traction continuously to ensure its effectiveness Explanation: The nurse must maintain skeletal traction continuously to ensure its effectiveness. The nurse should assess skin for breakdown; however, maintaining skeletal traction takes priority. Traction weights must hang freely to be effective; they should never be supported. The nurse should increase, not restrict, the client's fluid and fiber intake (unless contraindicated by a concurrent illness) to prevent constipation associated with complete bed rest. pg.1114

Which of the following statements is accurate regarding care of a plaster cast? a) The cast must be covered with a blanket to keep it moist during the first 24 hours. b) The cast will dry in about 12 hours. c) A dry plaster cast is dull and gray. d) The cast can be dented while it is damp.

d) The cast can be dented while it is damp. Explanation: The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding. pg.1104