Chapter 62 Medsurg nursing

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? a. Progressive leg exercises to obtain 90-degree flexion b. Early ambulation with full weight bearing on the left leg c. Bed rest for 3 days with the left leg immobilized in extension d. Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A Although early ambulation is not done, the patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a CPM machine. The patient's knee is unlikely to dislocate.

The patient had frostbite on the distal areas of the toes on both feet. The patient is scheduled for amputation of the damaged tissue. Which assessment finding or diagnostic study is the most objective indicator for locating the level of the patient's injury? a. Arteriography showing blood vessels b. Peripheral pulse assessment bilaterally c. Patches of black, indurated, and cold tissue d. Bilateral pale and cool skin below the ankles

A Arteriography is the most objective study to determine viable tissue for salvage based on perfusion because actual blood flow through the tissues is observed in real time. It is considered the gold standard for evaluating arterial perfusion. Bilateral peripheral pulse assessment, areas of black, indurated, and cold tissue, and bilateral pale and cool skin all identify the lack of tissue perfusion, but not the specific area where tissue perfusion stops and amputation needs to occur.

The patient had a lumbar spine arthrodesis. What should the nurse include in discharge teaching (select all that apply)? a. Do not smoke cigarettes. b. You should not walk for 3 weeks. c. You must wear your brace at all times. d. You may drive as soon as you feel like it. e. Do not bend your spine until your follow-up appointment.

A, E After a spinal fusion, the patient should not smoke cigarettes as nonunion tends to occur more often with smokers. Preventing pressure by not bending or twisting the spine or lifting more than 10 pounds will facilitate healing. The amount of time that is needed will be determined by the surgeon at follow-up appointments, but healing usually takes 6 to 9 months. An important aspect of healing is progressively increasing walking, which increases circulation of nutrients and oxygen for healing. If a brace is ordered to protect the surgical area, the surgeon will order how often the patient should wear it. Driving is not done until the surgeon allows it and the patient is no longer taking opioids for pain.

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle accident? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions. DIF: Cognitive Level: Analyze (analysis) REF: 1518 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "You will need to check and clean the pin insertion sites daily." b. "The external fixator can be removed for your bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the 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 when an external fixator is used. DIF: Cognitive Level: Apply (application) REF: 1516 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

ANS: B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position. DIF: Cognitive Level: Apply (application) REF: 1516 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing. DIF: Cognitive Level: Apply (application) REF: 1513 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

38. Before assisting a patient with ambulation 2 days after a total hip replacement, which action is most important for the nurse to take? a. Observe the status of the incisional drain device. b. Administer the ordered oral opioid pain medication. c. Instruct the patient about the benefits of ambulation. d. Change the hip dressing and document the wound appearance.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1526 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. After being hospitalized for 3 days with a right femur fracture, a 32-year-old 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? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolus, 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 oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained. DIF: Cognitive Level: Apply (application) REF: 1528 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. A patient who slipped and fell in the shower at home has a proximal humerus fracture immobilized with a left-sided long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 1524 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

34. The day after a 60-year-old patient has an open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely. DIF: Cognitive Level: Apply (application) REF: 1514 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

The home care nurse visits a 74-year-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? a. 2 × 6 cm right calf abrasion with sanguineous drainage b. Left leg externally rotated and shorter than the right leg c. Stooped posture with a shuffling gait and slow movements d. Mild pain and minimal swelling of the right ankle and foot

B Clinical manifestations of a hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. What would be an appropriate nursing intervention for this patient? a. Promote vitamin C and calcium intake in the diet. b. Provide passive range of motion to all of the joints q4hr. c. Encourage isometric quadriceps-setting exercises at least qid. d. Keep the left leg in extension and abduction to prevent contractures.

C Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery along with a continuous passive motion (CPM) machine. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to do active range of motion to all joints. Keeping the leg in one position (extension and abduction) potentially will result in contractures.

The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4-week checkup that healing is indicated by a. formation of callus. b. complete bony union. c. hematoma at fracture site. d. presence of granulation tissue.

Correct answer: a Rationale: Bone goes through a remarkable reparative process of self-healing (i.e., union) that occurs in stages. The third stage is callus formation. As minerals (i.e., calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts. Callus is composed primarily of cartilage, osteoblasts, calcium, and phosphorus. It usually appears by the end of the second week after injury. Evidence of callus formation can be verified on x-rays.

During the postoperative period, the nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes a. hip flexion contractures. b. skin irritation and breakdown. c. clot formation at the incision site. d. increased risk of wound dehiscence.

Correct answer: a Rationale: Flexion contractures may delay the rehabilitation process after amputations. The most common and debilitating contracture is hip flexion. To prevent flexion contractures, patients should avoid sitting in a chair for more than 1 hour with hips flexed or with pillows under the surgical extremity. Unless specifically contraindicated, patients should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone.

A patient with a fracture of the pelvis should be monitored for a. changes in urine output. b. petechiae on the abdomen. c. a palpable lump in the buttock. d. sudden increase in blood pressure.

Correct answer: a Rationale: Pelvic fractures may cause serious intraabdominal injury, such as paralytic ileus, hemorrhage, and laceration of the urethra, bladder, or colon. Patients may survive the initial pelvic injury, only to die of sepsis, fat embolism syndrome, or thromboembolism. Because a pelvic fracture can damage other organs, the nurse should assess bowel and urinary elimination and distal neurovascular status.

3 A posterior hip dislocation due to severe injury may result in avascular necrosis if the joints remain unreduced for a long time. The dislocated parts may block the blood supply to the bone, resulting in bone death and necrosis. The open joint injuries are susceptible to infection but are not associated with avascular necrosis. Intraarticular injuries are another complication of dislocation and may not be related to avascular necrosis. The adjacent neurovascular tissue will be manifested by altered neurovascular status. Text Reference - p. 1511

The nurse cares for a patient who experiences a severe hip injury. What condition places the patient at risk for avascular necrosis? 1 Open joint injury 2 Intraarticular injury 3 Inadequate blood supply to the bone 4 Damaged adjacent neurovascular tissue

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

b, d Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant relief of pain and improvement of function for a patient with osteoarthritis (OA).

A 28-year-old woman with a fracture of the proximal left tibia in a long leg cast complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which action should the nurse take? a. Notify the health care provider immediately. b. Elevate the left leg above the level of the heart. c. Administer prescribed morphine sulfate intravenously. d. Apply ice packs to the left proximal tibia over the cast.

A Clinical manifestations of compartment syndrome include (1) paresthesia, (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment, (3) pressure increases in the compartment, (4) pallor, coolness, and loss of normal color of the extremity, (5) paralysis or loss of function, and (6) pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient's changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

An injured soldier had an amputation of his left leg and is reporting shooting pain and heaviness in the area of his missing leg. What would be the best response by the nurse for this patient? a. Use mirror therapy. b. Give opioid analgesics. c. Rebandage the residual limb. d. Show the patient the leg is gone.

A Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone will not decrease phantom limb pain.

A 19-year-old male patient has a plaster cast applied to the right upper extremity for a Colles' fracture after a skateboarding accident. Which action, if taken by the nurse, is the most appropriate? a. Elevate the right arm on two pillows for 24 hours. b. Apply heating pad to reduce muscle spasms and pain. c. Limit movement of the thumb and fingers on the right hand. d. Place arm in a sling to prevent movement of the right shoulder.

A The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. The casted extremity should be elevated at or above the heart level to reduce swelling or inflammation. Ice should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

1 Bursitis is the inflammation of the bursae located near the joints. Rheumatoid arthritis causes inflammation in the joints, resulting in friction between joint surfaces. The repetitive kneeling involved in occupations such as coal mining may result in bursitis. A shin splint are is inflammation along the anterior aspect of the calf due to periostitis. A rotator cuff tear is a muscle tear around the shoulder joint. Impingement syndrome is also a shoulder injury. Text Reference - p. 1511

A coal miner with a history of rheumatoid arthritis reports pain, swelling, and a limited range of motion in the knee joints. What diagnosis does the nurse suspect? 1 Bursitis 2 Shin splints 3 Rotator cuff tear 4 Impingement syndrome

3 The elastic bandage should not be wrapped for prolonged periods, because it may irritate the area and cut off circulation. The bandage should not be wrapped too tightly, because it may interfere with the blood supply and cause numbness. The ideal way of wrapping the bandage is to start from the distal end and progress to the proximal area. The bandage should be wrapped for 30 minutes and removed for 15 minutes. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Text Reference - p. 1507

A nurse applies an elastic bandage to a patient's knee and provides discharge instructions after teaching the patient how to reapply the bandage. Which statement made by the patient indicates the need for further teaching? 1 "I will wrap it tightly but ensure that there is no numbness." 2 "I will wrap it starting from distal to proximal end." 3 "I will leave it in place for prolonged periods." 4 "I will leave it in place for 30 minutes and then remove it for 15 minutes."

3 Reconstructive therapy involves the removal of a torn anterior cruciate ligament tissue and its replacement with an allograft tissue. The patient's physical functioning may return to normal in six to eight months. ROM exercises are encouraged soon after the surgery to prevent complications related to prolonged immobilization. The knee is placed in a brace or immobilized after surgery. Progressive weight-bearing is determined by the degree of surgical repair. Text Reference - p. 1511

A nurse provides postoperative instructions to a patient who underwent reconstructive surgery for an anterior crucial ligament (ACL) injury. Which statement made by the patient indicates the need for further teaching? 1 "I should do range-of-motion (ROM) exercises." 2 "My knees should be kept immobilized while healing." 3 "It is not likely that my physical functioning will ever return to normal." 4 "Progressive weight-bearing may be critical for healing."

3, 4 The presence of brown tissue (iris or ciliary body) on the surface of the globe, extrusion of vitreous humor, and an eccentric or teardrop-shaped pupil indicate rupture of the globe. When such an injury is suspected, it is important to stop the examination and place a protective shield over the involved eye. Assessment of the function of the cranial nerves and sending the patient for a CT scan are done in the case of any facial fractures, but they aren't directly related to the eye assessment. Because this is a case of globe rupture, antibiotic eyedrops should be given only per the prescription of an ophthalmologist. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax. Text Reference - p. 1529

A patient has an injury to the eye. On examination, the nurse finds a brown tissue on the surface of the ocular globe and a teardrop-shaped pupil. What should the nurse do next? Select all that apply. 1 Assess for the function of cranial nerves. 2 Send the patient for a computed tomography (CT) scan. 3 Stop further examination of the eye. 4 Place a protective shield over the eye. 5 Put antibiotic eyedrops in the eye.

3 Subluxation, also known as dislocation, may be assessed by means of palpation of the space between the head of the bone and the cavity where it is normally located. Subluxation results in partial loss of function and intense pain. A subluxation is not a fracture—there is no break in bone integrity—but a subluxation is treated similarly to a fracture. With subluxation, there is no rupture in the integrity of the bone. Subluxation may be described as a misalignment, but this is not an accurate term. Text Reference - p. 1507

A patient is found to have a partially dislocated shoulder. How should the nurse document this finding? 1 Fracture 2 Rupture 3 Subluxation 4 Misalignment

3 A clicking, popping, and locking sensation with knee instability along with a positive McMurray's test indicate a meniscus injury. If untreated for a prolonged period, the meniscus injury may result in quadriceps atrophy due to disuse of the muscle. Bursitis is inflammation of the bursae and is not due to a meniscus injury. Avascular necrosis results from a lack of blood flow to the bones and does not occur due to untreated meniscus injury. A pathologic fracture is not associated with the prolonged lack of treatment of meniscus injury. Text Reference - p. 1511

A patient reports a clicking, popping, and locking sensation with knee instability and tests positive when performing McMurray's test. Which condition can occur in the patient, if this is left untreated? 1 Bursitis 2 Avascular necrosis 3 Quadriceps atrophy 4 Pathologic fracture

4 A third degree sprain involves complete tearing of the ligament, and a gap in the muscle may be apparent or be palpated through the skin. The swelling may occur due to the inflammatory responses by the released mediators but is not specific to the degree of sprain. Redness may or may not be present. The patient may feel pain due to the injury irrespective of the degree of the sprain, but the pain becomes severe in a third degree sprain. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer. Text Reference - p. 1506

A patient states, "I twisted my ankle while walking." Which assessment finding make the nurse suspect that the injury is a third degree sprain? 1 Swelling around the ankle 2 Redness of the skin around the ankle 3 Pain on movement of the ankle 4 Muscle gap on palpation of the skin around the ankle

4 Severe injury may result from posterior hip dislocation due to damage to the ligament structure around the joint. The presence of hemarthrosis indicates an intraarticular fracture and bleeding into the joint space. Bursitis is the inflammation of closed sae bursae. Arthrofibrosis is the "freezing" of the shoulder after prolonged immobilization after surgery. Avascular necrosis is associated with inadequate blood supply, resulting in bone cell death. Text Reference - p. 1508

A patient sustains a severe hip injury with dislocation in the posterior direction. Joint aspiration reveals hemarthrosis. What condition does the nurse suspect? 1 Bursitis 2 Arthrofibrosis 3 Avascular necrosis 4 Intraarticular fracture

4 The shoulder of a patient who underwent acromioplasty should not be immobilized for a prolonged time, because it may cause arthrofibrosis. Weight lifting is recommended if the patient has fully recovered. Physical therapy and pendulum exercises begin from the first postoperative day to promote healing and prevent complications. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1510

A patient with an extensive tear of the muscles around the shoulder underwent acromioplasty. Which postoperative activity may result in arthrofibrosis? 1 Lifting weights after six months 2 Beginning physical therapy on the first postoperative day 3 Performing pendulum exercises on the first postoperative day 4 Keeping the shoulder immobilized for prolonged periods after surgery

1 Shaking the hands often relieves CTS symptoms. Washing hands with water will not relieve the symptoms. Cold application is performed to promote healing of sprains. Warm, moist heat is applied 24 to 48 hours after a sprain injury. Text Reference - p. 1509

A patient with carpal tunnel syndrome (CTS) reports being awakened at night due to tingling and numbness in the hands. Which activity should the nurse instruct the patient to perform to relieve the symptoms? 1 "Shake your hands." 2 "Wash your hands with water." 3 "Apply cold packs to your hands." 4 "Apply warm, moist heat to your hands."

3. The occupational health nurse will teach the patient whose job involves many hours of typing about the need to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

ANS: A Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling. DIF: Cognitive Level: Apply (application) REF: 1509 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

30. Which nursing action for a patient who has had right hip replacement surgery can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain level and tolerance.

ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 1514 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

12. A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 1522 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a 62-year-old patient who has an intracapsular fracture of the right femur? a. Check peripheral pulses. b. Ask about hip pain level. c. Assess for hip contractures. d. Monitor for hip dislocation.

ANS: B Buck's traction keeps the leg immobilized and reduces 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. DIF: Cognitive Level: Apply (application) REF: 1525 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

42. Which information obtained by the nurse about a 29-year-old patient with a lumbar vertebral compression fracture is most important to report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1528 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

29. A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

ANS: B Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied. DIF: Cognitive Level: Apply (application) REF: 1507 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. A patient is being discharged 4 days after hip replacement surgery using the posterior approach. Which patient action requires immediate intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1526 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates that the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

ANS: B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected 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 nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. DIF: Cognitive Level: Apply (application) REF: 1521 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

19. The day after a having a right below-the-knee amputation, a patient complains of pain in the right foot. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Inform the patient that this phantom pain will diminish over time.

ANS: B Phantom limb sensation is treated like 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. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now. DIF: Cognitive Level: Understand (comprehension) REF: 1532 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A 22-year-old tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will work with a physical therapist tomorrow." c. "The doctor will use the drop-arm test to determine the success of surgery." d. "Leave the shoulder immobilizer on for the first 4 days to minimize pain."

ANS: B 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 (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation. DIF: Cognitive Level: Apply (application) REF: 1510 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

39. When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.

ANS: B 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. DIF: Cognitive Level: Understand (comprehension) REF: 1509 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding is important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. There are ecchymoses across the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 1524 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. When doing discharge teaching for a 19-year-old patient who has had a repair of a fractured mandible, the nurse will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

ANS: B The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires 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. DIF: Cognitive Level: Apply (application) REF: 1529-1530 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient to nursing assistive personnel (NAP).

ANS: B 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 this skill. DIF: Cognitive Level: Apply (application) REF: 1528 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

37. A patient undergoes a left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. place the patient in a prone position. b. check the surgical site for hemorrhage. c. remove the prosthesis and wrap the site. d. keep the residual leg elevated on a pillow.

ANS: B The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period. DIF: Cognitive Level: Apply (application) REF: 1532 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. Which statement by a 62-year-old patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lay flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

ANS: B 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 flexion contracture. DIF: Cognitive Level: Apply (application) REF: 1532 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

45. When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor the skin under the traction boot for redness. b. Ensure that the weight for the traction is off the floor. c. Check for intact sensation and movement in the affected leg. d. Offer reassurance that hip and leg pain are normal after hip fracture.

ANS: B UAP can be responsible for maintaining the integrity of the traction once it has been established. Assessment of skin integrity and circulation should be done by the registered nurse (RN). UAP should notify the RN if the patient experiences hip and leg pain because pain and effectiveness of pain relief measures should be assessed by the RN. DIF: Cognitive Level: Apply (application) REF: 1514 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying. DIF: Cognitive Level: Apply (application) REF: 1515 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

40. Which action will the urgent care nurse take when caring for a patient who has a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Avoid palpation or movement of the knee. c. Apply a knee immobilizer to the affected leg. d. Administer intravenous narcotics for pain relief.

ANS: C 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 usually recommended for pain relief. DIF: Cognitive Level: Apply (application) REF: 1510 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

28. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function. DIF: Cognitive Level: Apply (application) REF: 1508 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

46. Based on the information shown in the accompanying figure and obtained for a patient in the emergency room, which action will the nurse take first? a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's oxygen saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.

ANS: C Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's oxygen saturation. The other actions are also appropriate, but not as important at this time as obtaining the patient's oxygen saturation. DIF: Cognitive Level: Apply (application) REF: 1523 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

1. When teaching seniors at a community recreation center, which information will the nurse include about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 1506 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

4. Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce the amount of 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. DIF: Cognitive Level: Apply (application) REF: 1508 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm plaster cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast. DIF: Cognitive Level: Apply (application) REF: 1520 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

24. When giving home care instructions to a patient who has comminuted forearm fractures and a long-arm cast on the left arm, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Keep the hand immobile to prevent soft tissue swelling. c. Call the health care provider for increased swelling or numbness of the hand. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDs) for 24 hours after the injury.

ANS: C 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 pain after a fracture. DIF: Cognitive Level: Apply (application) REF: 1520 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

43. When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 1529 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

36. A 42-year-old patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture. DIF: Cognitive Level: Apply (application) REF: 1517-1518 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

31. A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.

ANS: C The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range-of-motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned. DIF: Cognitive Level: Apply (application) REF: 1508 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for a left hand arthroplasty. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 1535 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

32. Following a motorcycle accident, a 58-year-old patient arrives in the emergency department with massive left lower leg swelling. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess the circulation to the leg and to 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. DIF: Cognitive Level: Apply (application) REF: 1518 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

33. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. check the pedal pulses. d. verify tetanus immunizations.

ANS: C The initial nursing action should be assessment of the neurovascular status 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 done if there is an open wound. DIF: Cognitive Level: Apply (application) REF: 1518 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. After the health care provider has recommended 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? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

ANS: C The initial nursing action should be to assess the patient's knowledge level and feelings about the options available. Discussion about the patient's option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state. DIF: Cognitive Level: Apply (application) REF: 1531 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

35. The second day after admission with a fractured pelvis, a 64-year-old patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the oxygen saturation. d. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses gas exchange. DIF: Cognitive Level: Apply (application) REF: 1523 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. Which action will the nurse include in the plan of care for a patient who has had a total right knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

ANS: D 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. Full weight bearing is expected before discharge. DIF: Cognitive Level: Apply (application) REF: 1535 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

44. After change-of-shift report, which patient should the nurse assess first? a. Patient with a Colles' fracture who has right wrist swelling and deformity b. Patient with a intracapsular left hip fracture whose leg is externally rotated c. Patient with a repaired mandibular fracture who is complaining of facial pain d. Patient with right femoral shaft fracture whose thigh is swollen and ecchymotic

ANS: D Swelling and bruising after a femoral shaft fracture suggest hemorrhage and risk for 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. DIF: Cognitive Level: Analyze (analysis) REF: 1512 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

41. Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 1523-1524 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. A 48-year-old patient with a comminuted fracture of the left femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the right leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture. DIF: Cognitive Level: Apply (application) REF: 1514 | 1520 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environmen

21. The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching. DIF: Cognitive Level: Apply (application) REF: 1526 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

2. A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 1509 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A nurse performs discharge teaching for a 58-year-old woman after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful? a. "I should not try to drive a motor vehicle for 2 to 3 weeks." b. "Leg-raising exercises are necessary for several months." c. "I will not have any restrictions now on hip and leg movements." d. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

B Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which response to this question? a. Recent knee trauma b. Debilitating joint pain c. Repeated knee infections d. Onset of "frozen" knee joint

B The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy. Recent knee trauma, repeated knee infections, and onset of "frozen" knee joint are not primary indicators for a knee arthroplasty.

3 Bursitis is the inflammation of the bursae. These are located at sites of friction such as between tendons and bones and near the joints. The most common sites of bursitis occurrence include the elbows, shoulders, and greater trochanters of the hip. The back, thighs, and abdomen are less likely to be affected. Text Reference - p. 1511

Which is a common site of bursitis? 1 Back 2 Thighs 3 Elbows 4 Abdomen

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of what in the preoperative period? a. Pain b. Left knee stiffness c. Left knee infection d. Left knee instability

C It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability may be present with osteoarthritis.

A 42-year-old man has a recent amputation of the left leg below the knee as a result of a heavy farm machinery accident. Which intervention should the nurse include in the plan of care for this patient? 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. Lay 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, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients 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.

A 21-year-old female soccer player has injured her anterior crucial ligament (ACL) and is having reconstructive surgery. The nurse knows that the patient will need more teaching when the patient makes which statement? a. "I probably won't be able to play soccer for 6 to 8 months." b. "They will have me do range of motion with my knee soon after surgery." c. "I can't wait to get this done now so I can play soccer for the next tournament." d. "I will need to wear an immobilizer and progressively bear weight on my knee."

C When the athlete has ACL reconstructive surgery, the patient does not understand the severity when planning to be back to playing soccer soon, as safe return will not occur for 6 to 8 months after initial range of motion, immobilization, and progressive weight bearing with physical therapy occurs.

3 Severe injury of the ligamentous structures surrounding the humerus is a dislocation. A strain is an excessive stretching of the muscle, its fascial sheath, or a tendon. A sprain generally represents an injury to the ligament structures surrounding a joint. Subluxation is a partial displacement of the joint surface. Text Reference - p. 1508

Which condition does the nurse anticipate if a patient experiences a severe injury to the ligament around the humerus bone? 1 Strain 2 Sprain 3 Dislocation 4 Subluxation

An indication of a neurovascular problem noted during assessment of the patient with a fracture is a. exaggeration of strength with movement. b. increased redness and heat below the injury. c. decreased sensation distal to the fracture site. d. purulent drainage at the site of an open fracture.

Correct answer: c Rationale: Musculoskeletal injuries have the potential for causing changes in the neurovascular status of an injured extremity. In cases of musculoskeletal trauma, application of a cast or constrictive dressing, poor positioning, and the physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of a peripheral evaluation (i.e., color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic evaluation (i.e., sensation, motor function, and pain).

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when a. the patient is unable to tolerate prolonged immobilization. b. the patient cannot tolerate the surgery of a closed reduction. c. a temporary cast would be too unstable to provide normal mobility. d. adequate alignment cannot be obtained by other nonsurgical methods.

Correct answer: d Rationale: A comminuted fracture has more than two bone fragments. Open reduction with internal fixation (ORIF) is indicated for a comminuted fracture and is used to realign and maintain bony fragments. Other nonsurgical methods can result in a failure to obtain satisfactory reduction. Internal fixation reduces the hospital stay and the complications associated with prolonged bed rest.

The nurse suspects an ankle sprain when a patient at the urgent care center relates a. being hit by another soccer player during a game. b. having ankle pain after sprinting around the track. c. dropping a 10-lb weight on his lower leg at the health club. d. twisting his ankle while running bases during a baseball game.

Correct answer: d Rationale: A sprain is an injury to the ligamentous structures surrounding a joint, and a wrenching or twisting motion usually causes it. Most sprains occur in the ankle and knee join

In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid a. lifting heavy objects. b. sleeping on the back. c. abduction exercises of the affected ankle. d. bearing weight on the affected leg for 6 weeks.

Correct answer: d Rationale: After total ankle arthroplasty (TAA), the patient may not bear weight for 6 weeks and must elevate the extremity to reduce and prevent edema. The patient must be careful to prevent postoperative infection and should maintain immobilization as directed by the physician.

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences a. increasing edema of the limb. b. muscle spasms of the lower arm. c. rebounding pulse at the fracture site. d. pain when passively extending the fingers.

Correct answer: d Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? a. The cast is not dry yet, and it may be damaged while using crutches. b. The nurse does not have anyone available to accompany the patient. c. Rest, ice, compression, and elevation are in process to decrease pain. d. Excess edema and other problems 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 will be elevated on pillows above the heart level to avoid excessive edema and compartment syndrome. The cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order? a. Administer a dose of prescribed analgesic before completing the order. b. Ask the physical therapist for a walker to limit weight bearing while getting out of bed. c. Keep the continuous passive motion machine in place while lifting the patient from bed to chair. d. Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? a. Paresthesia b. Pitting edema c. Poor venous return d. Compartment syndrome

D The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to a. avoid crossing his legs. b. use a toilet elevator on toilet seat. c. notify future caregivers about the prosthesis. d. maintain hip in adduction and internal rotation.

D The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? a. Administer enoxaparin (Lovenox). b. Provide range-of-motion exercises. c. Apply sequential compression boots. d. Immobilize the fracture preoperatively.

D To prevent fat emboli, the nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus from the bone 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.

3 The hip is the most common dislocation of the lower extremity and generally is associated with motor vehicle collisions. Falls from a high place generally result in a fracture. Osteoporosis of the hip joint is more likely to result in a fracture and not dislocation. Pathologic fractures secondary to a history of cancer are not associated with hip dislocations. Text Reference - p. 1586

The nurse is caring for a patient with a dislocated hip. The nurse knows that this type of injury is associated most commonly with: 1 Fall from a high place 2 Osteoporosis of the hip 3 Motor vehicle collisions 4 Pathologic fractures of the hip

2, 3, 5 The patient who recently underwent closed reduction therapy for realigning the hip dislocation is advised to restrict strenuous activities that strain the joint. The patient should gradually return to the normal activities. The patient should perform gentle ROM exercises to prevent motion limitations of the joint. Antibiotic prophylaxis is appropriate for patients with open fractures and large tissue defects. The application of warm and moist heat is useful in a strain injury. Text Reference - p. 1508

The nurse provides discharge education to a patient who had recently underwent closed reduction therapy for realigning a dislocated hip joint. What instruction is appropriate for the nurse to include in the care plan? Select all that apply. 1 "Take a prophylactic antibiotic." 2 "Restrict strenuous activities." 3 "Return to normal activities gradually." 4 "Apply warm, moist heat to the affected area." 5 "Perform gentle range-of-motion exercises."

1, 3, 5 Balance exercises help in preventing falls. Strengthening exercises help in building up muscle strength and bone density. Performing warm-up exercises before any vigorous activity reduces the risk of sprains and strains. A cane can assist in walking but does not reduce sprains or strains. Taking analgesics before exercise in the absence of injury or pain may be unnecessary. Text Reference - p. 1507

The nurse provides education to an athlete about how to avoid sprains and strains. Which suggestion is appropriate for the nurse to include? Select all that apply. 1 "Perform balancing exercises." 2 "Use a cane while walking." 3 "Perform strengthening exercises." 4 "Take an analgesic before exercising." 5 "Perform muscle warming up exercises before vigorous activities."

4 The application of warm compresses should be applied after the acute phase of injury as the risk of internal bleeding subsides. Ice should be applied to the ankle to reduce inflammation and pain. The ankle should be elevated to prevent swelling and encourage fluid drainage. The movement of the ankle should be restricted to relive pain and provide rest. Test-Taking Tip: Look for answers that focus on the patient or that are directed toward the patient's feelings. Text Reference - p. 1507

The nurse reviews the plan of care for the initial management of a patient with an injured ankle ligament. Which item listed on the care plan requires attention? 1 Apply ice to the ankle. 2 Limit movement of the ankle. 3 Keep the affected ankle elevated. 4 Apply warm, moist heat to the ankle.

4 The patient with a dislocation may have deformation injury to the humerus around the shoulder joint. Tearing of ligaments in the shoulder may not indicate a dislocation. Mild tears in the shoulder muscles may not indicate dislocation. Severe tearing in the shoulder muscles may not indicate dislocation. Text Reference - p. 1508

The nurse reviews the results of a magnetic resonance image (MRI) study that was performed on a patient with a severe shoulder injury. Which MRI finding has the potential risk of dislocation? 1 Tearing of the ligaments around the shoulder joint 2 Mild tears within the muscles around the shoulder joint 3 Severe tearing within the muscles around the shoulder joint 4 Deformation injury to the humerus around the shoulder joint

1, 2, 3 The positive results of the drop arm test and a tear seen in the MRI scan may indicate a rotator cuff injury. A tear in the rotator cuff may occur due to repeated overhead motions and can include heavy weight lifting, a blow to the upper arm, or falling onto an outstretched arm. The other activities such as working with vibrating power tools or using a computer keyboard and mouse frequently are not likely to cause a rotator cuff injury. Text Reference - p. 1510

The nurse reviews the test results of a patient that reports shoulder weakness with decreased range-of-motion (ROM). What activities may have contributed to the patient's condition? Select all that apply. 1 Lifting heavy weights 2 A blow to the upper arm 3 Falling onto an outstretched arm 4 Working with vibrating power tools 5 Using a computer keyboard frequently

3 CTS involves the compression of the median nerve, which enters the hand through the narrow confines of the carpal tunnel. A rotator cuff tear is a tear within the muscle or tendinoligamentous structures around shoulder. The entrapment of soft tissue structures under the coracoacromial arch of the shoulder is impingement syndrome. The injury to fibrocartilage of the knee, characterized by popping, clicking, tearing sensation, effusion, and swelling, is a meniscus injury. Text Reference - p. 1509

What is carpel tunnel syndrome (CTS)? 1 The tear within the muscle or tendinoligamentous structures around the shoulder 2 The entrapment of soft tissue structures under the coracoacromial arch of the shoulder 3 The compression of the median nerve that enters the hand through the narrow confines of the carpal tunnel 4 The injury to fibrocartilage of knee, characterized by popping, clicking, tearing sensation, effusion, and swelling

4 The anterior cruciate ligament injury may involve a tear from the bone attachments that form the knee. The patient may report a tight and painful effusion, and a joint aspiration may be needed. Application of ice interferes with transmission of pain impulses and may not help in joint effusion. Elevation of the knee relieves edema. Nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin may relieve the pain at the injury site, but may not relieve effusion. Text Reference - p. 1511

What is the best intervention for a patient with an anterior cruciate ligament (ACL) injury who evidences tight and painful effusion? 1 Applying ice 2 Elevating the knee 3 Administering aspirin 4 Preparing for aspiration

2, 3, 4 Muscle spasms are caused by involuntary muscle contraction after fracture, strain, or nerve injury. These may displace a nondisplaced fracture or prevent it from healing spontaneously. Therefore it is important to take measures to prevent muscle spasms. The affected extremity should be aligned appropriately. Thermotherapy may reduce muscle spasm. The extremity should be placed in a comfortable position. Massaging a muscle spasm may stimulate muscle tissue contraction, further increasing pain and spasm. Therefore it is not advisable to massage spasms. An isometric muscle-strengthening exercise regimen will not prevent muscle spasms in this injured patient.

What measures should a nurse take to prevent muscle spasms in cases of musculoskeletal injuries? Select all that apply. 1 Massage the muscle spasms. 2 Align the affected extremity appropriately. 3 Use thermotherapy on the affected extremity. 4 Place the affected extremity in a comfortable position. 5 Provide isometric muscle strengthening exercises.

1, 5 The peroneal nerve has motor and sensory functions. The motor function is assessed by looking for dorsiflexion of the foot, whereas the sensory function is assessed by looking for sensation on the dorsal aspect of the foot between the first and second toes. Plantar flexion of the foot and sensory supplies to the sole of the foot are the functions of the tibial nerve. The function of the peroneal nerve is not assessed by sensation in the sole of the foot between the third and fourth toes or by sensation in the dorsal part of the foot between the first and second toes, because the peroneal nerve does not supply these areas. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. Text Reference - p. 1518

When performing the physical examination of a patient, how should the nurse assess the function of the peroneal nerve? Select all that apply. 1 Assess dorsiflexion of the foot. 2 Assess plantar flexion of the foot. 3 Assess sensation in the sole of the foot between the first and second toes. 4 Assess sensation in the sole of the foot between the third and fourth toes. 5 Assess sensation in the dorsal part of the foot between the first and second toes.

1, 2 4, 5 A nurse plays a pivotal role in teaching patients to take appropriate measures to prevent injuries. Some of these measures include regularly using seat belts; avoiding drunken driving, using protective athletic equipment (helmets and knee, wrist, and elbow pads), and using safety equipment at work. Obeying the speed limit is sufficient; the nurse does not need to teach that people should always drive slower than the speed limit. The teaching should encourage people not to use the phone at all while driving; if an important call must be made, the driver should find a safe place to stop before making it. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation. Text Reference - p. 1518

When teaching a group of young adults, what general measures should a nurse teach to prevent injuries? Select all that apply. 1 Use seat belts regularly. 2 Avoid drunken driving. 3 Drive slower than the posted speed limit. 4 Use safety equipment at work. 5 Use protective athletic equipment. 6 While driving, talk on the phone only if the call is important.

1 A meniscus injury may be manifested as a popping, clicking, tearing sensation with effusion and swelling. Swimmers have repeated overhead arm movements and are not likely to suffer from this condition. Athletes who play basketball, soccer, and football have a higher risk of knee injury than swimmers. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. Text Reference - p. 1510

Which athlete is least likely to experience a meniscus injury, according to the nurse who is assisting in conducting sports physicals? 1 A swimmer 2 A soccer player 3 A football player 4 A basketball player

1 Bursitis is the inflammation in the closed sacs lined with synovial membrane that contain synovial fluid and are located between tendons and bones near the joints. The swelling is the primary manifestation of bursitis. Bursitis is characterized by painful joints and a warm sensation, but not a tingling sensation. The manifestation of altered neurovascular status may appear later in acute soft tissue injury. Text Reference - p. 1511

Which primary manifestation is associated with bursitis? 1 Swelling 2 Painless joints 3 Tingling sensation 4 Altered neurovascular status.