Unit 5 Review
The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?
"Crutch tips will not slip, even when wet." There is a need for further teaching when the client says that crutch tips won't slip even when wet. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.
A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?
"I need to avoid getting the cast wet." A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching
The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?
"I'm doing these exercises so I can begin to fasten my buttons and dress myself again." The client understands the purpose of the therapy and provides an incentive to comply with the exercises when the client states, "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." The statement, I'm doing this, so I can go home soon" may or may not be true and could relate to a number of factors other than use of the right hand. Saying it hurts but things always hurt at my age is an inaccurate statement. Saying the therapist will get mad if I don't do this is incorrect because it indicates imposition of staff values on the client and is suggestive of possible abuse.
A nurse is observing a patient in a skilled nursing facility using a walker. The nurse concludes that the walker is at proper height if the patient's elbows are bent to which angle while the patient is upright and grasping the handgrips?
15 to 30 degrees The height is correct if the patient's elbow is bent at a 15- to 30-degree angle while standing upright and grasping the handgrips
The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse would plan to tell the client to place the crutches in which position?
8 inches to the front and side of the client's toes The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance.
A client with right-sided weakness needs to learn how to use a cane. How would the nurse teach the client to position the cane?
? The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.
The nurse is caring for a client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action would the nurse take first?
Check the client's alignment in bed. A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described.
A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?
Chicken breast, broccoli, strawberries, and milk Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin and jelly have no nutrient value. Spaghetti is a complex carbohydrate.
The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority?
Immobilize the leg before moving the client. When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?
Impaired tissue perfusion Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.
The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performed which action?
Moves the cane when the right leg is moved The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through
The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What would the nurse expect to find when checking the client's sacral area?
Partial-thickness skin loss of the epidermis With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial, and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3, and tunneling develops during stage 4.
The nurse is checking the casted extremity of a client. The nurse would check for which sign indicative of infection?
Presence of a "hot spot" on the cast Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider (PHCP) should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.
What type of bandage turn should a nurse use for a stump that is a result of an amputation?
Recurrent turn Recurrent turn is used to cover distal parts of the body, such as the end of a finger, the skull, or the stump left by amputation. Spiral turn is used to bandage parts of the body that are uniform in circumference. Circular turn is used to anchor the bandage and to terminate the wrap. Figure-of-eight turn may be used to bandage and stabilize an elbow, knee, or ankle, or to immobilize and hold a fractured clavicle in position.
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
Serous drainage A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.
A nurse is caring for a patient with a cast on the left lower extremity. The nurse should
fold the stockinette over the outside edge of cast to protect from chafing. When caring for a patient with a cast, the nurse should fold the stockinette over the outside edge of the cast to protect the patient's skin from chafing. The casted leg should be elevated on pillows. Changing position may relieve pain. Adding extra padding may prevent chafing.
The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse would plan to perform which action?
A.Stay with the person and encourage the person to remain still. With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.
What is usually the first mechanical aid used when training an individual to walk after a stroke?
Correct Walker A walker is frequently the first mechanical aid used when training an individual to walk following a loss of function (such as a stroke) or surgical procedure (such as a hip or knee replacement) and is helpful because it offers a broad base of support. Lifts are used to move an immobile patient, not usually an ambulatory patient. Crutches and quad canes aid in ambulation but would not be the first aid used following a stroke.
The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How would the nurse teach the client to use the crutches?
Crutches and the left leg, then advance the right leg A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait. Putting the crutches and the right leg down then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then the right leg and left crutch down describes a two-point gait.
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function?
Provides comfort by reducing muscle spasms and provides fracture immobilization Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.
What is a serious concern when a patient's movement is restricted?
Respiratory complication One of the major concerns when a patient's movement is restricted is the development of respiratory complications. Hypostatic or nosocomial pneumonia is a serious respiratory infection and may result from restricted movement. Constipation, muscle atrophy, and pressure wounds are also complications of restricted movement, but they are not as life threatening as respiratory complications.
The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching?
The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching? There is a need for further teaching when the client states that crutches need to rest up underneath the arm. Crutches must not rest underneath the client's arm, because it could cause injury to the nerves of the brachial plexus. Crutches must be measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body.
The nurse is teaching a client how to walk with a cane. Which information would the nurse include? Select all that apply.
A.The cane should create no more than 30 degrees of flexion of the elbow. B.The top of the cane should be parallel to the greater trochanter of the femur. C.A straight leg cane is used if the client only needs minimal support for an affected leg. The cane should create no more than 30 degrees of flexion of the elbow, and the top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist. A straight leg cane is sometimes used if the client needs only minimal support for an affected leg. A hemi-cane or quad-cane provides a broader, not narrower, base for the cane and therefore more support. The cane is placed on the unaffected side and not the affected side.
A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) would take which action?
Notify the registered nurse. The client with pallor, slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. Regardless of the cause, the LPN notifies the registered nurse immediately, who will contact the primary health care provider. These signs can occur with constriction from a tight cast as well. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area.
A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:
left the brakes of the wheelchair unlocked. The brakes should always be locked when a wheelchair is not in motion, and especially when someone is being assisted in and out of a wheelchair.
A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:
numbness of distal limb. Pallor, numbness, or cyanosis indicates reduced circulation. Other adverse changes are coolness, diminished or absent pulses, and possibly pain.
A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:
overlap turns of the bandage equally Turns of the bandage should be overlapped evenly. The wrap should be applied from distal to proximal, maintaining even pressure or tension. Metal clips could fall off in the bed and injure the patient; tape or pins should be used if the bandage does not have an adherent strip.
Measures to improve oxygenation and help prevent pneumonia are (Select all that apply.)
range-of-motion (ROM) exercises. frequent turning. deep-breathing exercises.
The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:
set the proper flexion and extension limits. The nurse is responsible for securing the limb in the machine and setting the proper flexion and extension limits ordered by the primary care provider.
