MS 1 class questions
A patient sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this patient? Select all that apply. A.Sharp chest pain B.Acute onset of dyspnea C.Pain in the residual limb D.Absence of the popliteal pulse E.Blanching of the affected extremity
A,B
The patient is admitted to the med-surg unit with a fracture of the hip. The provider orders Russell traction. This type of traction is: A.skin traction applied to a lower extremity, with the extremity suspended above the bed. B.skeletal traction applied to a lower extremity. C.skin traction applied to an extended lower extremity. D.skin traction applied bilaterally to the lower extremities.
A
The patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives to the med-surg floor after surgery, which nursing action takes priority? A.Assess the surgical site for bleeding. B.Remove the prosthesis and wrap the site. C.Place the patient in a side-lying position. D.Keep the affected abducted at all times.
A
Which clinical indicator does the nurse expect to identify when assessing a patient admitted with a herniated lumbar disk? A.Pain radiating to the hip and leg B.Bowel and bladder incontinence C.Paralysis of both lower extremities D.Overgrowth of tissue on the lower back
A
A patient has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the patient states, "What happened to me? I don't remember a thing." What is the nurse's best response? A."Tell me what you think happened." B."You will remember more as you get better." C."You were in a work-related accident this morning." D."It was necessary to amputate your leg after the accident."
C
A patient underwent a below-the-knee amputation secondary to severe arterial insufficiency. When instructing the patient in residual limb care, which statement by the nurse is correct? A."You should inspect the incision carefully when you change the dressing every other day." B."You should wash the incision, dry it, and apply moisturizing lotion daily." C."You should rewrap the stump as often as needed." D."You should elevate the stump on pillows at all times to decrease swelling."
C
The nurse is evaluating the pin insertion site of a patient's skeletal traction. Which finding indicates a complication? A.presence of crusts around the pin insertion site B.serous drainage on the dressing C.pin moves slightly at insertion site D.patient does not feel pain at insertion site
C
The patient is being discharged with a long arm cast after a fall that resulted in a comminuted left forearm fracture. Which information would the nurse include? A.Keep the left shoulder elevated on a pillow or two. B.Avoid taking non-steroidal anti-inflammatory (NSAIDs) drugs. C.Call the health care provider for numbness of the left hand. D.Keep the left hand immobile to prevent soft tissue swelling.
C
What is the most important assessment for the nurse to make when assessing peripheral pulses on a patient who has a fractured lower left extremity? A.Strong contractility and rate of pulse of the unaffected limb B.Color of the skin and rhythm of pulse above the affected fracture site C.Amplitude and symmetry of pulses in both extremities D.Local temperature and visible pulsations bilaterally
C
The nurse is caring for a patient on the orthopedics floor who had an open reduction internal fixation (ORIF) two days ago for an open, displaced tibial fracture. Which nursing problem currently takes priority for this patient? A.Activity intolerance related to deconditioning B.Risk for constipation related prolonged bed rest and side effects of opioids C.Risk for infection related to disruption in skin integrity D.Risk for impaired skin integrity related to immobility
C; infection can kill you
The nurse is providing discharge teaching to a patient going home with an external fixation device in place. What should be included in the discussion? A."You will need someone to help you carefully remove the external fixator for your daily shower." B."You will remain on bed rest with only bathroom privileges until the bone healing is over 50% complete." C."You will need to take these prophylactic antibiotics daily until the fixator is removed." D."You will need to check and clean the pin insertion sites every day."
D
What is the primary purpose of wrapping the residual limb with an elastic bandage postoperative? A.Limits formation of blood clots B.Decreases likelihood of phantom limb sensation C.Prevents hemorrhage and covers the incision D.Supports the soft tissue and minimizes postop swelling
D
What should the nurse include in the plan of care for a patient who just had a posterior lumbar laminectomy? A.Encourage the patient to cough B.Reposition the patient by log rolling C.Assess the patient for indications of peritonitis D.Instruct the patient to bend the knees when turning
B
