Ch. 51 Flashcards
A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?
a.
Blood pressure increases to 130/86 mm Hg
b.
Traction weights are resting on the floor
c.
Oozing of clear fluid is noted at the pin site
d.
Capillary refill is less than 3 seconds
ANS: B
The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client’s blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.
DIF: Applying/Application REF: 1060
A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?
a.
“Assess distal pulses for potential compartment syndrome.”
b.
“Turn the client every 3 to 4 hours to promote cast drying.”
c.
“Use a cloth-covered pillow to elevate the client’s leg.”
d.
“Handle the cast with your fingertips to prevent indentations.”
ANS: C
When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.
DIF: Applying/Application REF: 1059
A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client’s history should the nurse recognize as an aspect that may impede healing of the fracture?
a.
Sedentary lifestyle
b.
A 30–pack-year smoking history
c.
Prescribed oral contraceptives
d.
Paget’s disease
ANS: D
Paget’s disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.
DIF: Understanding/Comprehension REF: 1056
An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?
a.
Assess the pedal pulses.
b.
Apply oxygen by nasal cannula.
c.
Increase the IV flow rate.
d.
Loosen the traction.
ANS: A
These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider’s prescription.
DIF: Applying/Application REF: 1053
A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client’s vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?
a.
Administer oxygen via nasal cannula.
b.
Re-position to a high-Fowler’s position.
c.
Increase the intravenous flow rate.
d.
Assess response to pain medications.
ANS: A
The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowler’s position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.
DIF: Applying/Application REF: 1054
A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?
a.
An 18-year-old male athlete with a fractured clavicle
b.
A 36-year old female with type 2 diabetes and fractured ribs
c.
A 55-year-old woman prescribed aspirin for rheumatoid arthritis
d.
A 74-year-old man who smokes and has a fractured pelvis
ANS: D
Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.
DIF: Applying/Application REF: 1054
A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?
a.
“Remove the traction when re-positioning the client.”
b.
“Inspect the client’s skin when performing a bed bath.”
c.
“Provide pin care by using alcohol wipes to clean the sites.”
d.
“Ensure that the weights remain freely hanging at all times.”
ANS: D
Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client’s skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.
DIF: Applying/Application REF: 1060
A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
a.
Immobilize the left arm.
b.
Assess the client’s distal pulse.
c.
Monitor for signs of infection.
d.
Administer prescribed steroids.
ANS: A
A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client’s arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
DIF: Applying/Application REF: 1058
A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?
a.
Meperidine (Demerol) 50 mg IV every 4 hours
b.
Patient-controlled analgesia (PCA) with morphine sulfate
c.
Percocet 2 tablets orally every 6 hours PRN for pain
d.
Ibuprofen elixir every 8 hours for first 2 days
ANS: A
Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this client’s pain management.
DIF: Understanding/Comprehension REF: 1061
A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?
a.
“The pain you are feeling does not actually exist.”
b.
“This type of pain is common and will eventually go away.”
c.
“Would you like to learn how to use imagery to minimize your pain?”
d.
“How would you describe the pain that you are feeling?”
ANS: D
The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the client’s pain before determining the best action.
DIF: Applying/Application REF: 1071
A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the client’s fingers are pale, cool, and slightly swollen. Which action should the nurse take first?
a.
Raise the arm above the level of the heart.
b.
Encourage range of motion.
c.
Apply heat to the affected hand.
d.
Bivalve the cast to decrease pressure.
ANS: A
Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.
DIF: Applying/Application REF: 1059
A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, “The cast is loose enough to slide off.” How should the nurse respond?
a.
“Keep your arm above the level of your heart.”
b.
“As your muscles atrophy, the cast is expected to loosen.”
c.
“I will wrap a bandage around the cast to prevent it from slipping.”
d.
“You need a new cast now that the swelling is decreased.”
ANS: D
Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client’s skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client’s muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.
DIF: Understanding/Comprehension REF: 1059
A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?
a.
Hypertension
b.
Constipation
c.
Infection
d.
Hematuria
ANS: D
The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.
DIF: Applying/Application REF: 1069
A nurse cares for a client placed in skeletal traction. The client asks, “What is the primary purpose of this type of traction?” How should the nurse respond?
a.
“Skeletal traction will assist in realigning your fractured bone.”
b.
“This treatment will prevent future complications and back pain.”
c.
“Traction decreases muscle spasms that occur with a fracture.”
d.
“This type of traction minimizes damage as a result of fracture treatment.”
ANS: A
Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.
DIF: Understanding/Comprehension REF: 1060
A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client’s pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
a.
Request a prescription to decrease the traction weight.
b.
Apply an antibiotic ointment and a clean dressing.
c.
Cleanse the area, scrubbing off the crusty areas.
d.
Obtain a prescription to culture the drainage.
ANS: D
These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.
DIF: Applying/Application REF: 1060
A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first?
a.
Intravenous morphine
b.
Oral acetaminophen
c.
Intravenous calcitonin
d.
Oral ibuprofen
ANS: C
The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.
DIF: Applying/Application REF: 1072
A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this client’s plan of care?
a.
Place pillows between the client’s knees.
b.
Encourage range-of-motion exercises.
c.
Administer prophylactic antibiotics.
d.
Implement strict bedrest in a supine position.
ANS: B
Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.
DIF: Applying/Application REF: 1073
An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?
a.
Remove the medical alert bracelet from the fractured arm.
b.
Immobilize the arm by splinting the fractured site.
c.
Place the client in a supine position with a warm blanket.
d.
Cover any open areas with a sterile dressing.
ANS: A
A client’s medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.
DIF: Applying/Application REF: 1058
A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
a.
Inability to maintain adduction of the affected arm for more than 30 seconds
b.
Shoulder pain that is relieved with overhead stretches and at night
c.
Inability to initiate or maintain abduction of the affected arm at the shoulder
d.
Referred pain to the shoulder and arm opposite the affected shoulder
ANS: C
Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience referred pain to the opposite shoulder. Pain is usually more intense at night and with overhead activities.
DIF: Understanding/Comprehension REF: 1079
A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?
a.
Pain of 4 on a scale of 0 to 10
b.
Numbness in the extremity
c.
Swollen extremity at the injury site
d.
Feeling cold while lying in bed
ANS: B
The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.
DIF: Understanding/Comprehension REF: 1064
After teaching a client with a fractured humerus, the nurse assesses the client’s understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?
a.
Baked fish with orange juice and a vitamin D supplement
b.
Bacon, lettuce, and tomato sandwich with a vitamin B supplement
c.
Vegetable lasagna with a green salad and a vitamin A supplement
d.
Roast beef with low-fat milk and a vitamin C supplement
ANS: D
The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.
DIF: Applying/Application REF: 1065
A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client’s pain?
a.
Meperidine (Demerol) injections every 4 hours around the clock
b.
Patient-controlled analgesia (PCA) pump with morphine
c.
Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain
d.
Morphine 4 mg intravenous push every 2 hours PRN for pain
ANS: B
The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.
DIF: Applying/Application REF: 1068
A phone triage nurse speaks with a client who has an arm cast. The client states, “My arm feels really tight and puffy.” How should the nurse respond?
a.
“Elevate your arm on two pillows and get ice to apply to the cast.”
b.
“Continue to take ibuprofen (Motrin) until the swelling subsides.”
c.
“This is normal. A new cast will often feel a little tight for the first few days.”
d.
“Please come to the clinic today to have your arm checked by the provider.”
ANS: D
Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not reassure the client that this is normal.
DIF: Applying/Application REF: 1054
A nurse cares for a client who had a long-leg cast applied last week. The client states, “I cannot seem to catch my breath and I feel a bit light-headed.” Which action should the nurse take next?
a.
Auscultate the client’s lung fields anteriorly and posteriorly.
b.
Administer oxygen to keep saturations greater than 92%.
c.
Check the client’s blood glucose level.
d.
Ask the client to take deep breaths.
ANS: B
The client’s symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the client’s pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client.
DIF: Applying/Application REF: 1055
