AH Quiz 2
The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Redness around the pin sites Pain on palpation at the pin sites Thick, yellow drainage from the pin sites Clear, watery drainage from the pin sites
Thick, yellow drainage from the pin sites
The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? "I can resume regular exercise tomorrow." "I can't eat food for the remainder of the day." "I need to stay off the leg entirely for the rest of the day." "I need to report a fever or swelling to my health care provider."
"I need to report a fever or swelling to my health care provider."
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? Clear mentation Minimal dyspnea Oxygen saturation of 85% Arterial oxygen level of 78 mm Hg
Clear mentation
The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? Simple fracture Greenstick fracture Compound fracture Comminuted fracture
Comminuted fracture
The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? Fever and chills Dyspnea and chest pain External rotation of the right leg Pallor, paresthesia, and pulselessness of the right lower leg
Dyspnea and chest pain
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? Elevated for 3 hours, then flat for 1 hour Flat for 3 hours, then elevated for 1 hour Flat for 12 hours, then elevated for 12 hours Elevated on pillows continuously for 24 to 48 hours
Elevated on pillows continuously for 24 to 48 hours
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? Infection under the cast The anxiety of the client Impaired tissue perfusion The recent occurrence of the fracture
Impaired tissue perfusion
The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? Arterial insufficiency Impaired venous return Impaired arterial circulation The presence of an infection
Impaired venous return
Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. Expect tingling and numbness in the extremity. Use a hair dryer set on a warm to hot setting to dry the cast. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.
Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated.
The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? Cold, bluish-colored fingers Numbness and tingling in the fingers Pain that increases when the arm is dependent Pain that is out of proportion to the severity of the fracture
Numbness and tingling in the fingers
The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Contact the primary health care provider. Massage the skin at the edges of the cast. Petal the cast edges with appropriate material. Place a small facecloth in the cast around the edges of the cast.
Petal the cast edges with appropriate material.
A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Allows bony healing to begin before surgery and involves pins and screws Provides rigid immobilization of the fracture site and involves pulleys and wheels Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? The client moves both crutches forward and then swings both feet forward to the crutches. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.
The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward.