Compound Fracture

The prescribed dose of morphine reads, "Administer morphine sulfate 0.1 mg/kg IV every 3-4 hours." Cora weighs 33 pounds. The tubex of morphine contains 5 mg/mL. What volume of medication should the nurse administer? (in mL)

0.3 mL 33lbs/2.2kg= 15 kg 15kg*0.1mg/kg=1.5 mg 1.5mg/5mg*1mL=0.3 mL

Cora arrives on the nursing unit with her traction intact. She has a boot cast on her lower leg. Which nursing intervention(s) should be included in the plan of care while Cora is in traction? (Select all that apply.) A. Remove the traction for 10 minutes every hour. B. Keep weights securely positioned on the floor. C. Assess toes for capillary refill and edema. D. Attach the ropes to the footboard to prevent sliding. E. Ensure that the amount of weight remains constant.

C.E. C-Decreased perfusion to the foot or increased edema could lead to a potentially life-threatening complication. E-The nurse should assess the amount of the weight regularly to ensure that no changes have been made to the prescribed amount of traction. Well-meaning family and friends or older children may remove weights.

The nurse notes that in addition to the pain Cora's foot is cool and pale with capillary refill of 5 seconds. What additional assessment should the nurse perform? A. Deep tendon reflexes B. Toe movement C. Skin turgor D. Lack of hair growth

B Neurovascular assessment includes the "5 Ps." They are pain, pallor, pulse, paresthesia, and paralysis. Changes indicate increasing pressure on the blood vessels and nerves supplying the extremity distal to the cast or injury.

Which feature identifies Cora's fracture as an open fracture? A. Depressed area over the fracture area. B. Bone fragments protruding through the skin. C. A partially bent appearance on x-ray. D. Multiple bone fragments visible on x-ray.

B. A compound, or open, fracture involves a disruption in the skin over the fracture. Since bone fragments are protruding through the skin, skin integrity has been lost. A compound fracture increases the risk for infection and bleeding.

Cora insists that the play activity include Eugenia, her invisible friend. While playing, Cora throws some toys on the floor and scolds Eugenia for dropping them. Cora's mother tells Cora that the activity cannot continue if Cora is going to throw her toys. How should the nurse respond to this situation? A. Remind the mother that Cora is seeking ways to maintain control while immobile. B. Help the mother develop a plan to reduce Cora's need for an imaginary friend. C. Support the mother's decision to hold Cora accountable for her own misbehavior. D. Advise the mother that imaginary playmates at this age indicate regressive behavior.

C. Imaginary friends serve many useful purposes in the preschool years. The nurse should reassure Cora's mother that the inclusion of the imaginary friend is a healthy behavior but support the mother's recognition that Cora should not use her imaginary friend to escape responsibility for her own misbehavior

Cora usually snacks on animal crackers in the morning. She has a box at her bedside. She asks the nurse if she can have some while her mother is away from the bedside. Which action should the nurse take? A. Tell Cora that she will need to wait for her mother to return before she can have a snack. B. Give Cora crackers to play with, but tell her not to eat any until her mother returns. C. Give Cora a few crackers and stay with her while she eats them D. Give Cora a few crackers and leave her alone to enjoy her snack while watching TV

C. It is important to maintain Cora's routine; therefore she should be allowed to have her usual morning snack. It is also important to supervise Cora because preschoolers have great imaginations and Cora may choose to hide some of the animal crackers in her cast if left alone while having her snack.

Cora has been resting comfortably since surgery. She is receiving morphine 1.5mg IV every 4 hours and has consistently indicated adequate pain control via the FACES pain scale and through her remarks to her mother, who has been staying at her bedside. Twenty hours after surgery, the nurse administers the next scheduled dose of morphine. Two hours later, Cora is crying and agitated. She points to her foot and cries, "There, there, it hurts there." Which nursing action has the highest priority? A. Administer a breakthrough dose of morphine. B. Redirect Cora's attention to a new toy. C. Assess the appearance of Cora's foot. D. Monitor Cora's vital signs and oxygen saturation.

C. Pain distal to the site may be the first sign of a serious complication needing immediate attention.

The nurse also monitors Cora's lab values. Which change in the serum lab values would most likely indicate the onset of osteomyelitis? A. Decreased hemoglobin (Hgb) B. Decreased calcium C. Increased erythrocyte sedimentation rate (ESR) D. Increased creatine phosphokinase (CPK)

C. The ESR will increase during an inflammatory process, which would be present in acute osteomyelitis, an infection of the bone.

Since Cora's parents are divorced, which parent should the nurse try to contact first? A. The parent from whose house the babysitter assumed care of Cora (physical custody). B. The parent in whose home Cora lives the majority of the time (physical custody). C. The parent who has been assigned legal custody of Cora by the court. D. Both parents must be contacted, even if they do not share joint legal custody of Cora.

C. The parent who has been assigned legal custody of the child is primarily responsible to give consent for medical care if at all possible. In many situations, however, the parent with physical custody may also be allowed by the court to give consent. If both parents share custody, then both are able to give consent for medical care.

Cora goes to surgery, where reduction and fixation is performed. Following surgery, Cora is transferred to the orthopedic nursing unit where she will be in skeletal traction for several weeks. Which traction is a type of skeletal traction? A. Buck extension B. 90-90 Femoral C. Russell D. Bryant

B. In this type of traction, a pin or wire is placed in the distal fragment of the femur and a cast is applied to the lower leg. Traction ropes are used to maintain a 90-degree flexion of both the hip and the knee.

Which snack selection is the best choice for Cora while she is immobilized? A. Pudding B. Popsicle C. Vanilla wafers D. Saltine crackers

A Pudding provides protein and calories, both of which are important for an immobile child who is at risk for negative nitrogen balance

The nurse assesses Cora for pain. Cora points to the FACES pain scale rating indicating a high level of pain, but she is lying still and seems vague about the location of the pain when asked by the nurse. A prescription for IV morphine every 3-4 hours is available. Cora was medicated with a dose of morphine 3 hours ago, and she will be going to surgery in about 1 hour. What action should the nurse implement? A. Administer another dose of morphine immediately. B. Administer a dose of morphine right before Cora goes to surgery. C. Use distraction rather than analgesics until Cora goes to surgery. D. Document that pain assessment findings are inconsistent.

A. Lack of activity may indicate pain in the preschooler, an age at which a child is normally always on the go. Preschoolers may not be able to localize pain clearly. The child has clearly identified the degree of pain on the FACES scale and should be medicated accordingly.

The UAP goes to the playroom to get Cora some toys. The UAP is planning to spend some time with Cora. Which activity is the best choice for Cora? A. Pretend beauty parlor B. Monopoly board game C. Fifty-piece puzzle D. Looking at picture books

A. Preschoolers enjoy imitative and dramatic play, and they especially enjoy adult "make believe." This activity will help Cora with fine motor skills, as well as communication skills, and should keep her engaged for a period of time. Preschoolers also enjoy things like village and farm sets, hand puppets, simple handicrafts, and letter flash cards.

When Cora returns for the cast removal, the nurse uses a doll that allows Cora to role-play the procedure of cast removal. The nurse tells Cora that the cast-cutter makes a noise, but if it touches her leg, it will probably feel like a "tickle." Cora's parents invite the nurse to attend a parenting class at Cora's preschool about car safety. A parent in the class states that her 5-year-old son is very mature for his age and feels more grown-up using an adult seatbelt. She states that he follows the rules much better when he gets to make decisions; therefore, he is more willing to keep the seatbelt buckled. She goes on to say that he is large for his age, weighing almost 50 pounds. How should the nurse respond? A. Reassure this parent that the child is large enough to safely use an adult seatbelt. B. Instruct this parent that the child's age and size still require the use of a safety seat. C. Support the parent's desire to increase the child's independent decision-making. D. Redirect the topic to types of injuries that occur when car seats are not used correctly.

B Children should remain in car safety seats until they weight 40 pounds. It is highly recommended that children then use a booster car safety seat until they weight at least 60 pounds, or until they are at least 8 years old. This raises the child to a height that is better able to accomodate the safe safe use of a car's seatbelt system, which is designed for adults.

Based on these assessment findings, the nurse recognizes that Cora has developed compartment syndrome. In addition to notifying the healthcare provider of this development, which action should the nurse implement? A. Apply a pressure dressing over the affected area. B. Obtain equipment needed for cast removal C. Encourage Cora to keep trying to move her toes. D. Place an ice pack over the affected area

B Compartment syndrome is the compression of structures, such as arteries and nerves, within a closed compartment in an extremity. This complication typically occurs within 24 hours of a fracture. It should be reported to the healthcare provider immediately because permanent damage can occur within 12 hours of identification of the syndrome. Cast removal is often necessary to relieve the pressure, and surgical fasciotomy is sometimes needed as well.

Cora's 17-year-old babysitter, who was brought to the hospital with Cora, sustained only minor bruises. Cora's parents are divorced, and the babysitter reports that they are both at work. If a staff member is unable to reach Cora's parents, what guidelines will determine the staff's ability to provide needed care? A. A minor child can give permission and consent for care and is then considered emancipated. B. Emergency care may be provided after a reasonable attempt to reach the parents has been made. C. Since the babysitter has responsibility for the child, she can give informed consent for needed procedures. D. A minor child can assent to care, which is equivalent to an adult giving informed consent for care.

B. Most healthcare facilities will provide emergency, life-saving medical care to a minor if unable to reach parents after a reasonable attempt has been made.

The nurse recognizes that Cora is at risk for the onset of osteomyelitis. Which nursing intervention should be included in the plan of care to prevent this complication? A. Petal the edges of the boot cast with adhesive tape. B. Cleanse around the pin site with half-strength hydrogen peroxide. C. Place an eggcrate mattress on the bed under the bed sheet. D. Apply an elastic stocking to the unaffected leg.

B. Persons with skeletal traction are at high risk for direct entry of microorganisms at the pin site. Cleansing the pin site with half-strength hydrogen peroxide may be initiated to reduce this risk.

Cora's mother tells the nurse that she doesn't know how to respond to Cora when the child expresses her anger. In teaching the mother, what response should the nurse suggest she use with Cora? A. You shouldn't act out by throwing things at me. B. I am sad that you are throwing things at me. C. I will not stay here if you keep throwing things. D. Throwing things is not the way good girls behave.

B. Preschoolers need limit-setting guidelines and discipline. The parent's response should focus on the activity, rather than the child. Phrasing a response beginning with "I" rather than "you" is less judging to the child.

The nurse identifies that a priority nursing diagnosis for Cora is "Injury risk for peripheral neurovascular compromise." Implementation of which nursing intervention will reduce this risk? A. Perform hourly assessment of Cora's level of consciousness. B. Initiate hourly assessment of Cora's foot distal to the fracture site. C. Assign an unlicensed assistive personnel (UAP) to measure Cora's vital signs hourly. D. Evaluate Cora for the presence of orthostatic hypotension.

B. The trauma to the leg can cause swelling and possible compromise of circulation and nerve function distal to the fracture site. Cora's food should be assessed hourly for signs of diminished function.

The nurse talks to Cora's parents about preparing her for cast removal. Which technique is most beneficial when preparing a preschooler for a procedure that may be frightening? A. Begin to talk to the child about the procedure several days in advance B. Remind the child that removing the cast means she can return to normal activities. C. Reassure the child that there is nothing "scary" about the procedure. D. Describe what the child will experience shortly before the procedure takes place

D Advance preparation increases the likelihood that the preschooler will fantasize about the procedure and develop undue fears. As a general guideline, the younger the child, the closer to the procedure the preparation should occur.

After three weeks the traction is discontinued, a long leg cast is applied, and Cora is scheduled for discharge from the hospital. For which problem should Cora's parents be instructed to contact the healthcare provider? A. The cast sounds hollow when tapped. B. Cora's capillary refill is less than 2 seconds. C. Cora complains of itching inside the cast. D. Warm spots are felt on the cast

D If the cast feels warm, has hot spots, drainage, bleeding, or an unusual odor, the healthcare provider should be notified so that further evaluation can be done to determine if an infection or skin breakdown has occurred

The nurse administers an additional dose of analgesic to Cora after conferring with the healthcare provider. The nurse learns about other client care needs that must be met on the unit. A client with a pelvic fracture is being transferred from the Emergency Department (ED) and a postoperative client with crutches needs assistance to ambulate to the bathroom. An LPN and UAP are available to work with the RN. Given the available nursing personnel, what staff assignment is best? A. Ongoing monitoring of Cora's foot by the LPN, while the RN assists the postoperative client with crutches, and the UAP determines if the new client has any immediate problems. B. Ongoing monitoring of Cora's foot by the UAP, while the RN assists the postoperative client with crutches, and the LPN determines if the new client has any immediate problems C. Ongoing monitoring of Cora's foot by the RN, while the UAP assists the postoperative client with crutches, and the LPN determines if the new client has any immediate problems D. Ongoing monitoring of Cora's foot by the LPN, while the UAP assists the postoperative client with crutches, and the RN determines if the new client has any immediate problems

D Ongoing monitoring of Cora's fot can be performed by the LPN since the RN has already made an assessment and taken action. The UAP can assist the client with crutches, which allows the RN to assess the problems of a new client. The RN is the ONLY member of the team who has the expertise to perform an admission assessment and determine client needs and problems.

The parent goes on to say that her son prefers sitting in the front seat. She states this is the safest place because her car is equipped with front and side airbags. When an older child is sitting on a booster seat, where is the best place to locate the seat. A. Front passenger seat of a car with airbags B. Front passenger seat of a car without airbags C. Back seat of a car with only a lap belt D. Back seat of a car with lap and shoulder belts

D The Centers for Disease Control recommends that children younger than 12 years of age be placed in the rear seat of cars to prevent injury to the head from hitting the dashboard and injury from airbags intended for the protection of adult-sized passengers. The shoulder belt reduces the risk that the child may double over the lap belt, which could cause injury to the abdomen and spinal cord. For the younger child, it is important to ensure that the shoulder harness fits correctly to prevent injury to the child's neck and face.

The nurse reminds Cora and her parents that the cast will take 1 to 2 days to dry completely. The parents demonstrate lifting the cast by holding it with the palms of their hands. What action should the nurse take? A. Ask the parents if they feel too overwhelmed to learn cast care at the present time. B. Demonstrate the correct technique for moving the cast using only the fingertips C. Suggest that Cora might be more comfortable if a pillow is used when moving the cast D. Acknowledge that the parents have correctly learned how to move the cast while it is wet.

D The palms of the hands should be used to move a wet cast to avoid finger indentions that cause pressure points.

Both of Cora's parents are reached and are on the way to the hospital. Both gave telephone consent for Cora's emergency care. The nurse performs an assessment of the affected leg. The nurse notes leg deformity, swelling, and ecchymosis. EMS documentation indicates the presence of crepitus. How is the presence of crepitus related to this femur fracture determined? A. Observe the area arround the fracture for swelling, pain, and tenderness. B. Observe the area distal to the fracture for spasms or rigidity. C. Gently palpate over or around the wound and listen for a crackling sound. D. Listen for a grating sound when the affected area is moved.

D. Crepitus is a grating sound heart upon movement of bone fragments.

After resolving the other client care needs, the RN returns to Cora's room. Which task should be delegated to the LPN at this time? A. Revise the plan of care to reflect the recent complication. B. Teach Cora's parents about compartment syndrome. C. Evaluate the effectiveness of the dose of morphine administered. D. Spend time with Cora to distract her from the discomfort.

D. This is an appropriate nursing responsibility for the LPN.

Several days later, Cora throws her toys at her mother. Her mother is in tears and asks the nurse, "Why does she only get angry with me? She never yells at the nurses or her father." What is the best response by the nurse? A. You are the one providing all the discipline. It is only natural for her to be angry at you. B. Do you believe she would be happier being with her father than with you? C. You should not allow her to become that angry because it is harmful for both of you. D. It is natural to be upset when your child expressed anger toward you.

D. This open-ended statement offers the mother the opportunity to continue to express her feelings about the situation. The nurse can then offer reassurance that this expression of anger by Cora is normal and help the mother find ways to deal with the situation.

Introduction

Four-year-old Cora Taylor is brought to the ER by ambulance following an automobile accident. The accident occurred while Cora was riding in the car with her babysitter. Cora sustained a compound fracture of the femur, which will require surgical reduction, followed by skeletal traction.

Conclusion

The nurse reviews care safety tips with all the parents. At the conclusion of the class, Cora's mother reports that Cora is completely recovered and has resumed all of her normal activities.