Chapter 51- Iggy

Question 1

1. 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

Answer 1

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.

Question 2

2. 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.”

Answer 2

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.

Question 3

3. 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

Answer 3

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.

Question 4

4. 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.

Answer 4

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.

Question 5

5. 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.

Answer 5

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.

Question 6

6. 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

Answer 6

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.

Question 7

7. 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.”

Answer 7

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.

Question 8

8. 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.

Answer 8

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.

Question 9

9. 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

Answer 9

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.

Question 10

10. 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?”

Answer 10

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.

Question 11

11. 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.

Answer 11

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.

Question 12

12. 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.”

Answer 12

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.

Question 13

13. 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

Answer 13

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.

Question 14

14. 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.”

Answer 14

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.

Question 15

15. 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.

Answer 15

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.

Question 16

16. 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

Answer 16

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.

Question 17

17. 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.

Answer 17

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.

Question 18

18. 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.

Answer 18

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.

Question 19

19. 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

Answer 19

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.

Question 20

20. 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

Answer 20

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.

Question 21

21. 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

Answer 21

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.

Question 22

22. 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

Answer 22

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.

Question 23

23. 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.”

Answer 23

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.

Question 24

24. 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.
    breathing will not assist this client.

Answer 24

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.

Question 25

25. A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, “I don’t want to live with only one leg. I should have died during the surgery.” How should the nurse respond?
    a. “Your vital signs are good, and you are doing just fine right now.”
    b. “Your children are waiting outside. Do you want them to grow up without a father?”
    c. “This is a big change for you. What support system do you have to help you cope?”
    d. “You will be able to do some of the same things as before you became disabled.”

Answer 25

ANS: C
The client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping. The nurse should not ignore the client’s feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being “disabled” as this labels the client and may fuel the client’s poor body image.

Question 26

26. After teaching a client who is recovering from a vertebroplasty, the nurse assesses the client’s understanding. Which statement by the client indicates a need for additional teaching?
    a. “I can drive myself home after the procedure.”
    b. “I will monitor the puncture site for signs of infection.”
    c. “I can start walking tomorrow and increase my activity slowly.”
    d. “I will remove the dressing the day after discharge.”

Answer 26

ANS: A
Before discharge, a client who has a vertebroplasty should be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

Question 27

27. A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client’s risk for infection?
    a. Wash the traction lines and sockets once a day.
    b. Release traction tension for 30 minutes twice a day.
    c. Do not place the traction weights on the floor.
    d. Schedule for pin care to be provided every shift.

Answer 27

ANS: D
To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client’s skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection.

Question 28

28. A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.)
    a. It leads to minimal blood loss.
    b. It allows for early ambulation.
    c. It decreases the risk of infection.
    d. It increases blood supply to tissues.
    e. It promotes healing.

Answer 28

ANS: A, B, E
External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

Question 29

29. An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)
    a. Temperature
    b. Urinary output
    c. Blood pressure
    d. Pupil reaction
    e. Skin color

Answer 29

ANS: B, C, E
With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client’s heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.

Question 30

3. A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)
   a. Administer additional opioids as prescribed.
   b. Elevate the extremity on pillows.
   c. Apply ice to the fracture site.
   d. Place a heating pad at the site of the injury.
   e. Keep the extremity in a dependent position.

Answer 30

ANS: A, B, C
The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema.

Question 31

4. A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client’s plan of care? (Select all that apply.)
   a. Elevate heels off the bed with a pillow.
   b. Ambulate the client on the first postoperative day.
   c. Push the client’s patient-controlled analgesia button.
   d. Re-position the client every 2 hours.
   e. Use pillows to encourage subluxation of the hip.

Answer 31

ANS: A, B, D
Postoperative care for a client who has ORIF of the hip includes elevating the client’s heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

Question 32

5. A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
   a. Edema – Increased capillary permeability
   b. Pallor – Increased blood blow to the area
   c. Unequal pulses – Increased production of lactic acid
   d. Cyanosis – Anaerobic metabolism
   e. Tingling – A release of histamine

Answer 32

ANS: A, C, D
Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.

Question 33

6. A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client’s teaching? (Select all that apply.)
   a. Frequently assess the ergonomics of the equipment being used.
   b. Take breaks to stretch fingers and wrists during working hours.
   c. Do not participate in activities that require repetitive actions.
   d. Take ibuprofen (Motrin) to decrease pain and swelling in wrists.
   e. Adjust chair height to allow for good posture.

Answer 33

ANS: A, B, E
Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

Question 34

7. A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this client’s teaching? (Select all that apply.)
   a. “The device has been custom made specifically for you.”
   b. “Your prosthetic is good for work but not for exercising.”
   c. “A prosthetist will clean your inserts for you each month.”
   d. “Make sure that you wear the correct liners with your prosthetic.”
   e. “I have scheduled a follow-up appointment for you.”

Answer 34

ANS: A, D, E
A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the client’s level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.