Fractures Flashcards
A patient presents with an open fracture of the tibia after a motor vehicle accident. What is the nurse’s priority when managing this patient?
A. Apply ice to the site to reduce swelling.
B. Cover the wound with a sterile dressing.
C. Immobilize the affected extremity with a splint.
D. Administer prescribed antibiotics.
Correct Answer: B. Cover the wound with a sterile dressing.
Rationale: Open fractures expose the bone to the environment, significantly increasing the risk of infection. Covering the wound with a sterile dressing minimizes contamination. While immobilization (C), ice application (A), and antibiotics (D) are important, preventing infection takes priority in this scenario.
A patient in skeletal traction reports severe pain unrelieved by medication. The nurse observes the extremity is pale, cool, and has diminished pulses. What is the nurse’s next action?
A. Apply cold compresses to the affected limb.
B. Administer additional prescribed pain medication.
C. Elevate the extremity above the level of the heart.
D. Notify the healthcare provider immediately.
Correct Answer: D. Notify the healthcare provider immediately.
Rationale: These findings are indicative of compartment syndrome, a medical emergency that requires prompt intervention. Elevation (C) and cold compresses (A) are contraindicated as they can further impair circulation. Additional pain medication (B) will not address the underlying cause.
A patient with a plaster cast for a tibial fracture asks how to care for the cast. Which statement by the patient indicates a need for further teaching?
A. “I will avoid getting the cast wet.”
B. “I will use a hairdryer on the cool setting to relieve itching inside the cast.”
C. “I will elevate my leg above heart level for the first 24 hours.”
D. “I will use a sharp object to scratch inside the cast if it itches.
Correct Answer: D. “I will use a sharp object to scratch inside the cast if it itches.”
Rationale: Inserting objects into the cast can cause skin damage or introduce infection. The other statements reflect correct cast care practices.
A nurse is teaching a group of nursing students about the stages of bone healing. Which statement by a student indicates a correct understanding?
A. “Granulation tissue forms within 24 hours of the fracture.”
B. “Callus formation can be seen on X-ray around day 14.”
C. “Ossification typically occurs within the first week after a fracture.”
D. “Bone remodeling is complete within 6 weeks post-fracture.”
Correct Answer: B. “Callus formation can be seen on X-ray around day 14.”
Rationale: Callus formation typically occurs around day 14 and is visible on X-rays. Granulation tissue develops between days 3-14, ossification starts weeks after the fracture, and remodeling can take a year or more.
Which finding in a patient with an amputation requires immediate nursing intervention?
A. The patient reports phantom limb sensation.
B. There is a small amount of serous drainage on the dressing.
C. The patient’s skin around the residual limb appears red and swollen.
D. The patient’s dressing is saturated with bright red blood.
Correct Answer: D. The patient’s dressing is saturated with bright red blood.
Rationale: Bright red blood indicates active bleeding, which could lead to hemorrhage and requires immediate intervention. Phantom limb sensation
(A) and small amounts of drainage (B) are normal post-operative findings. Redness and swelling (C) warrant further assessment but are not immediately life-threatening.
A nurse is caring for a patient with a spiral fracture of the femur. Which of the following most likely caused this type of fracture?
A. Repeated stress, such as running long distances
B. A high-impact trauma, such as a motor vehicle accident
C. Twisting forces applied to the bone
D. Osteoporosis causing spontaneous breakage
Correct Answer: C. Twisting forces applied to the bone
Rationale: Spiral fractures are caused by a twisting or rotational force, which results in a spiral-shaped break along the bone shaft.
The nurse is educating a patient with a fiberglass cast on their arm. Which statement indicates the patient understands proper care?
A. “I will avoid submerging my cast in water unless approved by my doctor.”
B. “I can insert a pencil into the cast to scratch an itch.”
C. “I will apply lotion to the edges of the cast to prevent skin irritation.”
D. “I can rest my arm in a dependent position to improve circulation.”
Answer : A
A is correct because fiberglass casts are typically water-resistant, but they should not be submerged in water unless explicitly approved by the doctor. Water can weaken the cast or cause skin irritation.
Rationale: Fiberglass casts are water-resistant but should not be submerged unless specifically indicated as waterproof by the provider. Inserting objects, applying lotion, or leaving the arm in a dependent position can cause complications.
A nurse is performing a neurovascular assessment on a patient with a leg fracture. Which finding requires immediate intervention?
A. Capillary refill of 2 seconds
B. The patient reports tingling in the affected limb
C. Warm skin and strong pulses distal to the fracture
D. Pain unrelieved by analgesics
Correct Answer: D. Pain unrelieved by analgesics
Rationale: Pain unrelieved by analgesics can indicate compartment syndrome, a medical emergency requiring prompt action to prevent permanent damage.
A patient with a closed reduction for a fractured radius asks why they need a cast. Which explanation is best?
A. “It prevents infection at the fracture site.
B. “It immobilizes the bone to promote proper healing.”
C. “It realigns the bone fragments.
D. “It reduces pain by improving blood flow.”
Correct Answer: B. “It immobilizes the bone to promote proper healing.
“Rationale: A cast helps immobilize the bone, ensuring proper alignment and allowing the healing process to progress.
Which patient is at the highest risk for developing a stress fracture?
A. A 65-year-old male with osteoporosis
B. A 25-year-old runner training for a marathon
C. A 30-year-old female recovering from a car accident
D. A 50-year-old office worker with a sedentary lifestyle
Correct Answer: B. A 25-year-old runner training for a marathon
Rationale: Stress fractures result from repetitive stress or overuse, commonly seen in athletes such as runners.
A patient with a femoral fracture has been placed in skeletal traction. Which intervention is a priority for the nurse?
A. Encourage the patient to perform isometric exercises.
B. Ensure the weights hang freely and are not touching the floor.
C. Apply ice packs to the traction site every 4 hours.
D. Adjust the weights as needed to maintain alignment.
Correct Answer: B. Ensure the weights hang freely and are not touching the floor.
Rationale: Proper alignment and traction require that weights hang freely. Adjusting weights is outside the nurse’s scope of practice and must be done by a provider.
A patient with a cast on their leg reports increasing pain despite taking prescribed pain medication. Upon examination, the nurse notes pallor and cool skin distal to the cast. What should the nurse do first?
A. Notify the healthcare provider immediately.
B. Administer additional pain medication.
C. Loosen the cast to relieve pressure.
D. Elevate the extremity above the heart.
Correct Answer: A. Notify the healthcare provider immediately.
Rationale: These findings suggest compartment syndrome, a medical emergency requiring immediate intervention. Loosening the cast without an order can cause further complications.
A nurse is caring for a patient post-femur fracture repair with external fixation. Which finding is most concerning?
A. Clear, odorless drainage at the pin site
B. Redness and swelling at the pin site
C. The patient reports body image concerns.
D. Muscle atrophy in the affected leg
Correct Answer: B. Redness and swelling at the pin site
Rationale: Redness and swelling can indicate infection at the pin site, which requires prompt evaluation and treatment.
A patient with an open reduction and internal fixation (ORIF) asks about MRI safety. What is the nurse’s best response?
A. “You cannot have an MRI if you have metal implants.
“B. “Some metal implants are MRI-compatible; your doctor will confirm this.
“C. “Metal implants have no impact on MRI safety.
“D. “You will need a CT scan instead of an MRI.”
Correct Answer: B. “Some metal implants are MRI-compatible; your doctor will confirm this.
“Rationale: Many modern implants are MRI-safe, but this should be confirmed by the healthcare provider or device manufacturer.
A nurse is teaching a patient with an arm cast about preventing complications. Which statement by the patient requires correction?
A. “I will move my fingers regularly to maintain circulation.
“B. “I can use a padded object to scratch an itch inside the cast.
“C. “I will elevate my arm on pillows to reduce swelling.
“D. “I will attend all my follow-up appointments.”
Correct Answer: B. “I can use a padded object to scratch an itch inside the cast.
“Rationale: Inserting any object into the cast can damage the skin or introduce bacteria, increasing the risk of infection.
A nurse is caring for a patient with a comminuted femoral fracture. Which intervention is most critical in the immediate postoperative period after open reduction and internal fixation (ORIF)?
A. Encourage early ambulation to prevent complications.
B. Assess for signs of infection at the surgical site.
C. Administer prescribed calcium and vitamin D supplements.
D. Educate the patient about proper cast care.
Correct Answer: B. Assess for signs of infection at the surgical site.
Rationale: Post-ORIF, the risk of infection is high due to the surgical intervention. Early detection of infection is critical to prevent complications. Ambulation (A), supplements (C), and cast care (D) are important but are not the highest priority in the immediate postoperative period.
A nurse is monitoring a patient with a long leg cast for a tibial fracture. The patient complains of increasing pain unrelieved by prescribed medication and has a capillary refill time of 5 seconds. Which action should the nurse take first?
A. Elevate the limb to improve circulation.
B. Remove the cast immediately.
C. Perform a neurovascular assessment of the affected limb.
D. Notify the healthcare provider.
Correct Answer: D. Notify the healthcare provider.
Rationale: Increasing pain unrelieved by medication and delayed capillary refill are early signs of compartment syndrome, requiring immediate provider intervention. Removing the cast (B) is not within the nurse’s scope of practice, and elevation (A) may worsen the condition.
A nurse is educating a patient with a new fiberglass cast. Which statement by the patient indicates a correct understanding of cast care?
A. “I will cover my cast with a plastic bag when I shower.”
B. “I can use lotion to keep the skin under my cast moisturized.”
C. “I will use a heating pad to keep the cast warm.”
D. “I can rest my leg in a dependent position to reduce swelling.”
Correct Answer: A. “I will cover my cast with a plastic bag when I shower.”
Rationale: Covering the cast protects it from getting wet, which is crucial to maintain its integrity. Using lotion (B) or a heating pad (C) can damage the skin or cast. Keeping the leg dependent (D) can increase swelling and should be avoided.
A patient with a pelvic fracture is at risk for a fat embolism. Which symptom is most concerning and requires immediate action?
A. Hypoxia and restlessness.
B. Pain at the fracture site.
C. Bruising around the hip area.
D. Swelling at the fracture site.
Correct Answer: A. Hypoxia and restlessness.
Rationale: Hypoxia and restlessness are signs of a fat embolism, a potentially life-threatening complication of long bone or pelvic fractures. Pain (B), bruising (C), and swelling (D) are expected findings with fractures but do not indicate immediate danger.
A nurse is preparing to educate a patient about the complications of compartment syndrome. Which statement by the nurse is correct?
A. “Elevating the limb above the heart helps reduce compartment pressure.”
B. “Applying ice packs is an effective way to control swelling and pressure.”
C. “You should report numbness or tingling in the affected limb immediately.”
D. “Compartment syndrome occurs within the first 24 hours of the injury.”
Correct Answer: C. “You should report numbness or tingling in the affected limb immediately.”
Rationale: Paresthesia (numbness or tingling) is an early sign of compartment syndrome and requires immediate attention. Elevation (A) and ice packs (B) can worsen ischemia. While symptoms can develop within 24 hours, they may also be delayed, making (D) incorrect.
A nurse is performing a neurovascular assessment on a patient with a fractured arm. Which finding indicates a potential complication?
A. Capillary refill of 2 seconds.
B. Skin that is warm and dry to the touch.
C. Paresthesia in the fingers of the affected arm.
D. Equal bilateral radial pulses.
Correct Answer: C. Paresthesia in the fingers of the affected arm.
Rationale: Paresthesia is an abnormal finding and can indicate nerve damage or compromised circulation. Capillary refill of 2 seconds (A), warm and dry skin (B), and equal pulses (D) are normal findings.
A patient undergoing skin traction for a femoral fracture is at risk for skin breakdown. What is the most appropriate nursing action?
A. Increase the traction weight to maintain proper alignment.
B. Massage reddened areas to improve circulation.
C. Regularly assess the skin under the traction device.
D. Use lotion on areas under pressure to prevent dryness.
Correct Answer: C. Regularly assess the skin under the traction device.
Rationale: Skin assessment is critical to identify early signs of breakdown. Increasing weight (A) and massaging reddened areas (B) can cause further damage. Lotions (D) can make the skin slippery, increasing the risk of pressure injury.
A nurse is caring for a patient 24 hours post-fasciotomy for compartment syndrome. Which intervention is most appropriate?
A. Elevate the limb above the level of the heart to prevent swelling.
B. Apply ice packs to the affected limb to reduce edema.
C. Assess the surgical site for signs of infection and drainage.
D. Perform passive range-of-motion exercises on the affected limb.
Correct Answer: C. Assess the surgical site for signs of infection and drainage.
Rationale: Post-fasciotomy, infection risk is high due to the open wound. Regular assessment is essential for early detection. Elevation (A) and ice (B) are contraindicated in compartment syndrome management, and passive ROM exercises (D) are not appropriate immediately post-surgery.
Which patient is at highest risk for developing a pathological fracture?
A. A 24-year-old athlete with a tibial stress fracture.
B. A 68-year-old patient with osteoporosis.
C. A 32-year-old with a transverse fracture of the femur.
D. A 45-year-old with a comminuted humeral fracture.
Correct Answer: B. A 68-year-old patient with osteoporosis.
Rationale: Pathological fractures occur in weakened bones due to conditions like osteoporosis or cancer. Patients with stress (A), transverse (C), or comminuted (D) fractures are less likely to have pathological causes for their fractures.
A patient is admitted with a long bone fracture and begins showing signs of respiratory distress, confusion, and petechiae on the chest. What is the nurse’s priority action?
A. Place the patient in a high-Fowler’s position.
B. Notify the healthcare provider immediately.
C. Administer prescribed oxygen via nasal cannula.
D. Prepare the patient for emergency surgery.
Correct Answer: B. Notify the healthcare provider immediately.
Rationale: The symptoms are indicative of a fat embolism, a medical emergency. While administering oxygen (C) is important, notifying the provider (B) ensures timely intervention. High-Fowler’s position (A) may help with breathing but is not the priority action. Surgery (D) is not typically indicated for fat embolism.
A nurse is caring for a patient with skeletal traction. Which finding requires immediate intervention?
A. The patient reports mild muscle spasms.
B. The traction weights are resting on the floor.
C. The patient has slight redness at the pin insertion site.
D. The patient uses the trapeze bar to shift position in bed.
Correct Answer: B. The traction weights are resting on the floor.
Rationale: Weights must hang freely to maintain proper alignment and traction. Mild muscle spasms (A) are expected initially. Redness at the pin site (C) requires monitoring but is not an emergency. Using the trapeze bar (D) is an appropriate action to maintain mobility and independence.
Which statement by a patient with an external fixator indicates a need for further teaching?
A. “I will clean the pin sites daily using aseptic technique.”
B. “I should report any redness, swelling, or drainage to my healthcare provider.”
C. “I can use lotion around the pin sites to prevent dryness.”
D. “I need to monitor for signs of loosening in the fixator.”
Correct Answer: C. “I can use lotion around the pin sites to prevent dryness.”
Rationale: Applying lotion around the pin sites increases the risk of infection. Cleaning with aseptic technique (A), monitoring for infection (B), and checking for loosening (D) are appropriate actions.
A nurse is assessing a patient with a casted arm who reports unrelieved pain despite prescribed analgesics. The nurse notes pale fingers, cool skin, and delayed capillary refill. What is the priority intervention?
A. Elevate the arm to improve circulation.
B. Assess for presence of a radial pulse.
C. Loosen the cast if possible.
D. Notify the healthcare provider immediately.
Correct Answer: D. Notify the healthcare provider immediately.
Rationale: These are signs of compartment syndrome, which is a medical emergency requiring immediate intervention. Loosening the cast (C) may not be within the nurse’s scope of practice. Elevation (A) is contraindicated, and assessing the radial pulse (B) delays critical action.
A patient with diabetes undergoes a below-the-knee amputation. What post-operative finding should the nurse report immediately?
A. The patient reports phantom limb pain.
B. The dressing is saturated with bright red blood.
C. The residual limb is edematous.
D. The patient has a blood glucose level of 140 mg/dL.
Correct Answer: B. The dressing is saturated with bright red blood.
Rationale: Saturated dressings indicate active bleeding, which requires immediate intervention. Phantom limb pain (A) and edema (C) are expected post-operative findings. A blood glucose level of 140 mg/dL (D) is within an acceptable range for a diabetic patient.
A patient with a femoral fracture in skeletal traction develops a fever, redness at the pin site, and purulent drainage. What is the nurse’s priority action?
A. Clean the pin site using aseptic technique.
B. Administer prescribed antibiotics.
C. Notify the healthcare provider.
D. Document the findings in the patient’s medical record.
Correct Answer: C. Notify the healthcare provider.
Rationale: These signs indicate a possible infection, requiring prompt medical evaluation and treatment. Cleaning the pin site (A) and administering antibiotics (B) are important but must be guided by the provider. Documentation (D) is necessary but not the immediate priority.
A patient is admitted with a spiral fracture of the humerus. The nurse knows this type of fracture is commonly associated with:
A. High-impact trauma, such as a car accident.
B. Repeated stress on the bone from activities like running.
C. Twisting injuries caused by shearing forces.
D. Underlying conditions like osteoporosis.
Correct Answer: C. Twisting injuries caused by shearing forces.
Rationale: Spiral fractures occur when a bone is subjected to a twisting force. High-impact trauma (A) is more likely to cause comminuted fractures. Repeated stress (B) leads to stress fractures, and underlying conditions (D) may result in pathological fractures.
A nurse is teaching a patient with a new lower leg cast about preventing complications. Which statement by the patient indicates the need for further teaching?
A. “I will elevate my leg above heart level for the first 24 hours.”
B. “I will move my toes frequently to maintain circulation.”
C. “I will report any numbness or tingling to my doctor immediately.”
D. “I will insert a cotton swab into the cast to relieve itching.”
Correct Answer: D. “I will insert a cotton swab into the cast to relieve itching.”
Rationale: Inserting objects into the cast can damage the skin and increase the risk of infection. The other statements are correct measures to prevent complications.
A patient with a closed reduction for a displaced radial fracture asks why a cast is necessary. The nurse explains:
A. “The cast provides comfort by reducing pain and swelling.”
B. “The cast ensures proper alignment and stabilization during healing.”
C. “The cast prevents the need for surgery in most cases.”
D. “The cast allows for immediate weight-bearing on the injured arm.”
Correct Answer: B. “The cast ensures proper alignment and stabilization during healing.”
Rationale: Casts are primarily used to stabilize fractures and maintain proper alignment during healing. While they may reduce pain (A), they do not necessarily prevent surgery (C) or allow immediate weight-bearing (D).
The nurse is caring for a patient post-fasciotomy for compartment syndrome. Which finding requires immediate action?
A. Bright red bleeding from the surgical site.
B. Serous drainage on the dressing.
C. Dark amber-colored urine output.
D. Pain controlled with prescribed analgesics.
Correct Answer: C. Dark amber-colored urine output.
Rationale: Dark amber urine may indicate rhabdomyolysis, a serious complication of muscle breakdown seen in compartment syndrome. This can lead to acute kidney injury and requires immediate intervention.
A patient recovering from a below-the-knee amputation is hesitant to use a prosthetic limb, stating, “I feel like people will stare at me.” What is the nurse’s best response?
A. “You’ll get used to it once you start wearing the prosthetic.”
B. “Many people use prosthetics and adapt well to them.”
C. “It’s normal to feel this way. Would you like to talk about it?”
D. “Your prosthetic will help you regain mobility and independence.”
Correct Answer: C. “It’s normal to feel this way. Would you like to talk about it?”
Rationale: Acknowledging the patient’s feelings and encouraging open communication is essential for addressing psychosocial concerns. The other responses minimize the patient’s emotions or focus on problem-solving without first addressing the underlying feelings.
A nurse is preparing a patient for discharge after a fracture treated with external fixation. Which discharge instruction is most important?
A. “Avoid lifting heavy objects for at least six weeks.”
B. “Keep the external fixator clean to prevent infection.”
C. “Perform weight-bearing exercises as tolerated.”
D. “Monitor for swelling and discoloration in the affected limb.”
Correct Answer: B. “Keep the external fixator clean to prevent infection.”
Rationale: Preventing infection is a primary concern with external fixation. While avoiding heavy lifting (A), performing exercises (C), and monitoring for complications (D) are important, infection prevention takes precedence.
A patient with an external fixator for a femur fracture asks about potential complications. Which statement by the nurse is most accurate?
A. “You may experience mild swelling and redness at the pin sites, which is normal.”
B. “You must avoid moving the limb to prevent loosening the fixator.”
C. “Watch for signs of infection, such as warmth, drainage, or a foul odor at the pin sites.”
D. “The fixator will need to be adjusted weekly to ensure proper healing.”
Correct Answer: C. “Watch for signs of infection, such as warmth, drainage, or a foul odor at the pin sites.”
Rationale: Infection is a significant risk with external fixators, and early recognition of signs like warmth, drainage, or foul odor is critical. Mild swelling and redness (A) require monitoring but are not always normal. Movement (B) is encouraged to prevent complications like muscle atrophy. Regular adjustments (D) depend on the provider’s recommendations but are not universally required.
A patient with a lower leg cast reports increasing pain despite taking prescribed analgesics. The nurse notes tightness around the cast and coolness in the toes. What is the nurse’s first action?
A. Administer additional pain medication as prescribed.
B. Reassess the patient in 30 minutes to monitor changes.
C. Bivalve (split) the cast to relieve pressure.
D. Notify the healthcare provider immediately.
Correct Answer: D. Notify the healthcare provider immediately.
Rationale: These findings suggest compartment syndrome, a medical emergency requiring immediate provider intervention. Splitting the cast (C) may be necessary but must be directed by the provider. Delaying action (B) or administering more medication (A) will not address the underlying issue.
A nurse is caring for a patient who underwent an open reduction internal fixation (ORIF) for a hip fracture. Which finding requires immediate intervention?
A. The patient reports mild discomfort at the surgical site.
B. The patient’s incision is red with minimal serous drainage.
C. The patient’s calf is swollen, warm, and tender to touch.
D. The patient has a blood pressure of 128/78 mmHg.
Correct Answer: C. The patient’s calf is swollen, warm, and tender to touch.
Rationale: These symptoms suggest a possible deep vein thrombosis (DVT), which requires immediate action to prevent complications like a pulmonary embolism. Mild discomfort (A), redness with minimal drainage (B), and normal blood pressure (D) are not urgent concerns.
A patient recovering from a closed reduction for a displaced fracture of the radius asks when they can start physical therapy. What is the nurse’s best response?
A. “You will start therapy once the cast is removed.”
B. “Physical therapy begins immediately to prevent stiffness.”
C. “Your healthcare provider will determine when therapy should begin.”
D. “Therapy will only be needed if you have difficulty regaining function.”
Correct Answer: C. “Your healthcare provider will determine when therapy should begin.”
Rationale: The timing of physical therapy depends on the provider’s evaluation of the patient’s healing progress and individual needs. Starting immediately (B) is not appropriate for a new cast, and waiting until the cast is removed (A) or only addressing functional difficulties (D) is not accurate.
- What is the earliest clinical manifestation of acute compartment syndrome (ACS)?
A. Pulselessness
B. Severe pain out of proportion to the injury
C. Paresthesia
D. Pallor
Correct Answer: B. Severe pain out of proportion to the injury
Rationale: Severe pain disproportionate to the injury is the earliest and most reliable sign of ACS. Pulselessness (A) and paresthesia (C) occur later. Pallor (D) is less common in the early stages
A nurse is caring for a patient with suspected ACS. Which diagnostic tool is most definitive in confirming the diagnosis?
A. X-ray
B. Serum creatinine phosphokinase (CPK) levels
C. Intracompartmental pressure measurement
D. Magnetic resonance imaging (MRI)
Correct Answer: C. Intracompartmental pressure measurement
Rationale: Measurement of intracompartmental pressure (ICP) is the gold standard for confirming ACS. X-rays (A) and MRI (D) are not diagnostic for ACS. Elevated CPK levels (B) may indicate rhabdomyolysis but do not confirm ACS
A patient with ACS has an intracompartmental pressure of 30 mmHg. What is the priority intervention?
A. Elevate the affected limb above the heart
B. Perform a fasciotomy
C. Apply ice packs to reduce swelling
D. Administer prescribed analgesics
Correct Answer: B. Perform a fasciotomy
Rationale: A pressure of 30 mmHg is critical, requiring immediate surgical decompression (fasciotomy) to prevent permanent damage. Elevation (A) above heart level is contraindicated, as it reduces arterial perfusion. Ice packs (C) and analgesics (D) are not sufficient
Which patient is at highest risk for developing ACS?
A. A 22-year-old male with a tibial shaft fracture
B. A 45-year-old female with a burn injury
C. A 60-year-old male with diabetic neuropathy
D. A 30-year-old female with a contusion
Correct Answer: A. A 22-year-old male with a tibial shaft fracture
Rationale: Tibial fractures are the most common cause of ACS, particularly in young males due to their larger muscle mass and tighter fascia
The nurse is assessing a patient with ACS. Which finding indicates late-stage ACS?
A. Pain with passive stretching of the limb
B. Poikilothermia in the affected limb
C. Pulselessness
D. Paresthesia
Correct Answer: C. Pulselessness
Rationale: Pulselessness is a late sign of ACS and indicates compromised arterial perfusion. Pain (A) is an early indicator, while poikilothermia (B) and paresthesia (D) occur earlier than pulselessness
What is the normal resting intracompartmental pressure in a limb?
A. 0-4 mmHg
B. 5-10 mmHg
C. 15-20 mmHg
D. 25-30 mmHg
Correct Answer: A. 0-4 mmHg
Rationale: Normal resting intracompartmental pressure is 0-4 mmHg. Higher pressures can indicate developing ACS
A patient with ACS has a delta pressure (difference between diastolic BP and compartment pressure) of 20 mmHg. What does this indicate?
A. Normal tissue perfusion
B. ACS requiring immediate intervention
C. Early signs of tissue ischemia
D. Impending rhabdomyolysis
Correct Answer: B. ACS requiring immediate intervention
Rationale: A delta pressure ≤ 30 mmHg is diagnostic of ACS, necessitating prompt treatment to prevent irreversible damage
Which intervention is contraindicated in managing ACS?
A. Keeping the limb at heart level
B. Elevating the limb above the heart
C. Administering oxygen
D. Removing constrictive dressings
Correct Answer: B. Elevating the limb above the heart
Rationale: Elevating the limb above the heart reduces arterial perfusion, worsening ischemia in ACS. Keeping the limb at heart level (A) maintains optimal circulation
Which clinical finding is most indicative of nerve ischemia in ACS?
A. Loss of light touch sensation
B. Poikilothermia
C. Pallor
D. Delayed capillary refill
Correct Answer: A. Loss of light touch sensation
Rationale: Loss of light touch sensation is an early sign of nerve ischemia due to pressure on the deep peroneal nerve. Other signs, such as poikilothermia (B) and pallor (C), are less specific
The nurse is caring for a post-fasciotomy patient. Which assessment finding requires immediate action?
A. Serous drainage at the incision site
B. Pink, viable tissue in the wound
C. Swelling of the unaffected limb
D. Loss of sensation in the affected limb
Correct Answer: D. Loss of sensation in the affected limb
Rationale: Loss of sensation may indicate ongoing or recurrent ischemia, requiring urgent intervention. Serous drainage (A) and pink tissue (B) are expected findings post-fasciotomy
What is the hallmark feature of ACS that differentiates it from other conditions like cellulitis or DVT?
A. Severe pain with passive stretch
B. Erythema and swelling
C. Pitting edema
D. Warmth at the affected site
Correct Answer: A. Severe pain with passive stretch
Rationale: Severe pain with passive stretch is a hallmark of ACS and helps differentiate it from other conditions
A nurse is teaching a group of students about ACS. What statement indicates the need for further teaching?
A. “Early symptoms of ACS include severe pain and paresthesia.”
B. “ACS is more common in males due to larger muscle mass.”
C. “Pulselessness is an early sign of ACS.”
D. “Timely fasciotomy prevents permanent damage.”
Correct Answer: C. “Pulselessness is an early sign of ACS.”
Rationale: Pulselessness is a late sign of ACS, not an early one. The other statements are correct
Which compartment of the lower leg is most commonly involved in ACS?
A. Anterior
B. Lateral
C. Deep posterior
D. Superficial posterior
Correct Answer: A. Anterior
Rationale: The anterior compartment is the most commonly affected in lower leg ACS
A patient is diagnosed with rhabdomyolysis secondary to ACS. Which lab finding confirms this condition?
A. Serum creatinine phosphokinase (CPK) > 1,000 IU/L
B. Decreased urine specific gravity
C. Hypercalcemia
D. Hypokalemia
Correct Answer: A. Serum creatinine phosphokinase (CPK) > 1,000 IU/L
Rationale: Elevated CPK levels indicate muscle damage and rhabdomyolysis, commonly associated with ACS
Which postoperative measure is most critical after a fasciotomy for ACS?
A. Early ambulation
B. Frequent neurovascular checks
C. Application of warm compresses
D. Keeping the wound tightly closed
Correct Answer: B. Frequent neurovascular checks
Rationale: Frequent neurovascular assessments ensure the compartment is adequately decompressed and monitor for complications
The nurse is assessing a patient with suspected acute compartment syndrome (ACS). Which clinical manifestations support this diagnosis? (Select all that apply.)
A. Severe pain unrelieved by analgesics
B. Paresthesia in the affected limb
C. Brisk capillary refill
D. Pallor of the extremity
E. Pulselessness in the affected limb
Correct Answers: A, B, D, E
Rationale: Severe pain (A) is the earliest sign of ACS. Paresthesia (B), pallor (D), and pulselessness (E) occur as the condition progresses. Brisk capillary refill (C) is not a typical finding in ACS
Which interventions are appropriate for the nurse to implement when managing a patient with acute compartment syndrome? (Select all that apply.)
A. Elevate the limb above the heart
B. Remove tight dressings
C. Prepare the patient for a fasciotomy
D. Apply cold compresses to the affected area
E. Keep the limb at heart level
Correct Answers: B, C, E
Rationale: Removing tight dressings (B) and keeping the limb at heart level (E) help optimize circulation. Preparing for a fasciotomy (C) is critical as it is the definitive treatment. Elevation above the heart (A) and cold compresses (D) are contraindicated
A nurse is teaching a patient with a cast about warning signs of complications. Which symptoms should the patient report immediately? (Select all that apply.)
A. Increased pain not relieved by medication
B. Numbness or tingling in the extremity
C. Warmth and redness at the cast edges
D. Inability to move the fingers or toes
E. Swelling of the extremity that does not improve with elevation
Correct Answers: A, B, D, E
Rationale: Pain unrelieved by medication (A), numbness or tingling (B), inability to move extremities (D), and persistent swelling (E) are signs of neurovascular compromise or potential ACS. Warmth and redness at the cast edges (C) may indicate irritation but not necessarily a critical issue
Which patients are at increased risk for developing acute compartment syndrome? (Select all that apply.)
A. A 28-year-old male with a tibial fracture
B. A 35-year-old female with tight splints applied after a burn
C. A 45-year-old male with a blunt forearm trauma
D. A 60-year-old female with diabetic neuropathy
E. A 70-year-old male recovering from total knee arthroplasty
Correct Answers: A, B, C, E
Rationale: Tibial fractures (A), tight splints (B), blunt trauma (C), and orthopedic surgeries like total knee arthroplasty (E) are common causes of ACS. Diabetic neuropathy (D) is not directly related to ACS development
The nurse is performing a neurovascular assessment on a patient with a leg injury. Which findings indicate a complication? (Select all that apply.)
A. Capillary refill greater than 3 seconds
B. Pale, cool skin on the affected limb
C. Dorsalis pedis pulse is 2+ bilaterally
D. Patient reports numbness in the toes
E. Severe pain with passive movement of the limb
Correct Answers: A, B, D, E
Rationale: Delayed capillary refill (A), pale and cool skin (B), numbness (D), and severe pain with passive movement (E) are concerning signs of neurovascular compromise or ACS. Bilateral pulses of 2+ (C) are normal
A nurse is caring for a post-fasciotomy patient. Which postoperative care measures should be implemented? (Select all that apply.)
A. Apply a wound vacuum-assisted closure device
B. Monitor for signs of infection
C. Elevate the limb above the level of the heart
D. Perform frequent neurovascular assessments
E. Administer prescribed pain medication
Correct Answers: A, B, D, E
Rationale: Wound VAC (A), infection monitoring (B), neurovascular assessments (D), and pain management (E) are critical postoperative care measures. Elevating the limb above the heart (C) is contraindicated
The nurse is educating a group of nursing students about the 6 P’s of acute compartment syndrome. Which components should be included? (Select all that apply.)
A. Pain
B. Pulselessness
C. Prolonged capillary refill
D. Pallor
E. Poikilothermia
Correct Answers: A, B, D, E
Rationale: The 6 P’s include pain (A), pulselessness (B), pallor (D), poikilothermia (E), paresthesia, and paralysis. Prolonged capillary refill (C) is not part of the 6 P’s
Which diagnostic measures can assist in confirming acute compartment syndrome? (Select all that apply.)
A. Serum creatinine phosphokinase (CPK) levels
B. Delta pressure calculation
C. Intracompartmental pressure measurement
D. Magnetic resonance imaging (MRI)
E. X-ray imaging
Correct Answers: A, B, C
Rationale: Elevated CPK levels (A), delta pressure (B), and intracompartmental pressure measurement (C) are used to diagnose ACS. MRI (D) and X-rays (E) are not primary diagnostic tools for ACS
A nurse is managing a patient with a cast. What actions should be avoided to prevent complications? (Select all that apply.)
A. Inserting objects into the cast to relieve itching
B. Elevating the casted extremity
C. Allowing the cast to remain wet
D. Applying direct pressure to the cast while drying
E. Using a hair dryer on the cast to speed up drying
Correct Answers: A, C, D, E
Rationale: Inserting objects (A), keeping the cast wet (C), applying direct pressure (D), and using a hair dryer (E) are contraindicated. Elevating the extremity (B) is appropriate
A patient presents with rhabdomyolysis secondary to ACS. Which lab findings are expected? (Select all that apply.)
A. Serum creatinine phosphokinase (CPK) > 1,000 IU/L
B. Presence of urine myoglobin
C. Elevated serum potassium
D. Hypercalcemia
E. Low serum creatinine
Correct Answers: A, B, C
Rationale: Rhabdomyolysis involves elevated CPK levels (A), urine myoglobin (B), and hyperkalemia (C) due to muscle breakdown. Hypercalcemia (D) and low creatinine (E) are not typical findings
