Fractures & Complications

Question 1

A patient presents to the emergency department after an accident with injury to the right leg. A radiograph of the right femur shows a fracture. Which does the nurse include during the peripheral vascular assessment of the patient? Select all that apply.

A. Pain
B. Color
C. Edema
D. Motor function
E. Capillary refill

Answer 1

B. Color
C. Edema
E. Capillary refill

Rationale:
In cases related to fractures, peripheral vascular assessment should be done. This consists of assessment of color, temperature, capillary refill, peripheral pulses, and edema. Assessment of motor function and pain is included in the peripheral neurologic assessment.
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Question 2

After a motor vehicle crash, a patient has a dislocated right hip joint and the bone is exposed in the right thigh. The patient’s x-ray shows more than two fragments. Which type of fracture does the nurse document? Select all that apply.

A. Open
B. Closed
C. Displaced
D. Comminuted

Answer 2

A. Open

Rationale
In this case, the bone is exposed; therefore it is an open fracture. Comminuted fractures have two or more fragments of bones. Fractures can be classified as displaced or nondisplaced. In a displaced fracture, the two ends of the broken bone are
separated from one another and are out of their normal positions. This fracture is not a closed one because the fractured bone is exposed through soft tissue injury. Greenstick fracture is a type of fracture in which the periosteum is intact across the fracture and the bone is still in alignment.

Question 3

Which type of fracture is most common in adults greater than 65 years of age?

A. Hip fracture
B. Pelvic fracture
C. Colles fracture
D. Fracture of the humerus

Answer 3

A. Hip fracture

Rationale:
Hip fractures are most common in older adults, with 90% of these fractures occurring as a result of a fall. Colles’ fracture is a fracture of the distal radius and is one of the most common fractures in adults of any age. Pelvic fractures range from benign to life-threatening, depending on the mechanism of injury and associated vascular insult. Only a small percentage of all fractures are pelvic fractures. This type of injury is associated with a high mortality rate. Fractures of the humerus involve the shaft of the humerus and are common among young and middle-aged adults.

Question 4

A patient experiences a greenstick fracture. The nurse reviews the patient’s x-ray results and expects which finding?

A. An incomplete fracture with one side splintered and the other side bent

B. A fracture with more than two fragments; the smaller fragments appear to be floating

C. The line of the fracture extends across and down the bone

D. The line of the fracture extends in a spiral direction along the bone shaft.

Answer 4

A. An incomplete fracture with one side splintered and the other side bent

Rationale
A greenstick fracture is an incomplete fracture with one side splintered and the other side bent. A comminuted fracture is a fracture with more than two fragments; the smaller fragments appear to be floating. An oblique fracture is when the line of the fracture extends across and down the bone. A spiral fracture is when the line of the fracture extends in a spiral direction along the bone shaft.

Question 5

A patient arrives in the emergency department after sustaining a fall. The initial assessment reveals that the left leg is shorter than the right and externally rotated. Which condition does the nurse suspect?

A. Fractured hip
B. Fracture pelvis
C. Fractured tibia/fibula
D. Nondisplaced fractured femur

Answer 5

A. Fractured hip

Rationale
Older adults, especially women, are at high risk for fractures. One classic sign of a fractured hip is a leg that is shorter than the opposite one and abnormally rotated (internally or externally). A fractured hip is accompanied by pain and possibly neurovascular changes. A leg that is shorter than the other one and externally rotated is not a sign of a fractured pelvic, femur, or tibia/fibula.

Question 6

A patient with a fracture of the femur is being treated with Buck’s traction. How does the nurse explain the functions of Buck’s traction to the patient? Select all that apply.

A. It immobilizes the fracture.
B. It reduces muscle spasms.
C. It reduces injury-related edema.
D. It prevents or reduces pain.
E. It helps in the union of the fractured bone.

Answer 6

A. It immobilizes the fracture.
B. It reduces muscle spasms.
D. It prevents or reduces pain.

Rationale
Traction is the application of a pulling force to an injured or diseased part of the body, often an extremity. A Buck’s traction boot is a type of skin traction used to immobilize the fracture, prevent or reduce pain, and reduce muscle spasms. The traction does not reduce edema or directly help in the union of the fractured bone. However, it
indirectly helps the process of union of the fractured bone by keeping the limb aligned and reducing spasms and contractures.

Question 7

A patient is admitted to the hospital with an open fracture. Which actions does the nurse take to prevent infection of the wound? Select all that apply.

A. Administer prophylactic antibiotics before surgery.
B. Ensure airway, breathing, and circulation.
C. Assess the neurovascular status of the limb.
D. Administer tetanus and diphtheria prophylaxis.
E. Immobilize the affected extremity in the position in which it was found

Answer 7

A. Administer prophylactic antibiotics before surgery.
D. Administer tetanus and diphtheria prophylaxis

Rationale
The nurse will give tetanus and diphtheria toxoid or tetanus immunoglobulin to the patient with an open fracture who has not been previously immunized or whose immunization is expired. Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin), are used prophylactically before surgery. Open fractures are predisposed to be contaminated, and therefore patients are exposed to a higher risk of infection.
Other measures, including assessing the neurovascular status of the limb; ensuring airway, breathing, and circulation; and immobilizing the affected limb in the position in which it was found are also important, but these activities do not help in preventing infection of the open fracture wound.

Question 8

The nurse provides education for a community group related to osteoporosis. Which statement made by a member of the group indicates the need for further education?

A. People with osteoporosis should take calcium and vitamin D supplements.”

B. “Older adults may have low bone density, which increases their risk for fractures.”

C. “Fragility fractures are often associated with osteoporosis.”

D. “In adults over 65 years old, hip fracture occurs more often in men than in women because of osteoporosis.”

Answer 8

D. “In adults over 65 years old, hip fracture occurs more often in men than in women because of osteoporosis.”

Rationale
In adults over 65 years old, hip fracture occurs more often in women than in men because of osteoporosis. People with osteoporosis should take calcium and vitamin D supplements. Older adults may have low bone density, which increases their risk for fractures. Fragility fractures are often associated with osteoporosis.

Question 9

Which patients will the nurse assess for signs and symptoms of osteomyelitis? Select all that apply.

A. A 60-year-old diabetic who has a blunt injury
B. A 14-year-old old boy who sustained an ankle sprain
C. A 50-year-old man who underwent a total hip replacement
D. A 20-year-old woman with a closed fracture of the humerus
E. A 30-year-old man with a tibia fracture and a deep wound over it

Answer 9

A. A 60-year-old diabetic who has a blunt injury
C. A 50-year-old man who underwent a total hip replacement
E. A 30-year-old man with a tibia fracture and a deep wound over it

Rationale
Osteomyelitis is the infection of the bone, its marrow, and the soft tissues surrounding it. The 60-year-old patient with diabetes mellitus will have vascular insufficiency and a suboptimal immune system, facilitating the spread of microorganisms, and resulting in osteomyelitis. The 50-year-old man who underwent a total hip replacement can be a potential source of infection. An open fracture with a deep wound may facilitate an easy access for microorganisms to get to the bone, resulting in osteomyelitis. The 14-year-old boy who sustained an ankle sprain would not develop osteomyelitis due to having a good immune system and an injury limited to soft tissues. The 20-year-old woman with a closed fracture of the humerus may not develop osteomyelitis due to the closed nature of the injury.

Question 10

The nurse is providing postoperative care two days after a patient underwent surgical repair of a fractured hip. Which assessment finding indicates the need for immediate nursing action?

A. Pain at the surgical site
B. Sudden shortness of breath
C. Serosanguineous wound drainage
D. Limited range of motion of the affected leg

Answer 10

B. Sudden shortness of breath

Rationale
The sudden onset of shortness of breath could be an indication of fat embolism syndrome (FES), a potentially fatal complication of long bone fractures. Pain at the surgical site, serosanguineous wound drainage, and limited range of motion of the affected leg are all expected findings in a patient who has just undergone repair of a fractured hip.

Question 11

The patient presents to the emergency department with a femur fracture. Which nursing intervention does the nurse implement to prevent fat embolism syndrome (FES)?

A. Administer enoxaparin.
B. Provide range-of-motion exercises.
C. Apply sequential compression boots.
D. Immobilize the fracture preoperatively.

Answer 11

D. Immobilize the fracture preoperatively.

Rationale
To prevent FES, the nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus from the bone before surgical reduction. Enoxaparin is used to prevent blood clots, not FES. Range-of- motion exercises and compression boots will not prevent FES in this patient.

Question 12

The nurse is caring for a patient immediately after the patient sustained a hip fracture. Which nursing action is performed first?

A. Administering pain medication
B. Preparing for immediate surgery
C. Immobilizing the affected extremity
D. Placing the injured extremity in traction

Answer 12

C. Immobilizing the affected extremity

Rationale
The priority of emergency management for a fractured hip is immobilizing the
affected extremity because movement could cause further damage and more extensive internal bleeding and worsen the patient’s pain. Administering pain medication, preparing the patient for immediate surgery, and placing the injured extremity in traction are secondary nursing interventions that require further direction from the health care provider.

Question 13

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and would include which action in the plan?

A. Ensure that the knots are at the pulleys.
B. Check the weights to ensure that they are off the floor.
C. Ensure that the head of the bed is kept at a 45- to 90-degree angle.
D. Monitor the weights to ensure that they are resting on a firm surface.

Answer 13

B. Check the weights to ensure that they are off the floor.

Rationale:
To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights would not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

Question 14

The nurse is caring for an older adult who has been placed in Buck’s extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

A. Apply restraints to the client.
B. Ask the family to stay with the client.
C. Place a clock and calendar in the client’s room.
D. Ask the laboratory to perform electrolyte studies.

Answer 14

C. Place a clock and calendar in the client’s room.

Rationale:
An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client’s room to maintain orientation. Restraints may cause further disorientation and would not be applied unless specifically prescribed; agency policies and procedures need to be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

Question 15

The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client?

A. Urinary incontinence
B. Signs of skin breakdown
C. The presence of bowel sounds
D. Signs of infection around the pin sites

Answer 15

B. Signs of skin breakdown

Question 16

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

A. Redness around the pin sites
B. Pain on palpation at the pin sites
C. Thick, yellow drainage from the pin sites
D. Clear, watery drainage from the pin sites

Answer 16

C. Thick, yellow drainage from the pin sites

Rationale:
The nurse needs to monitor for signs of infection, such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse needs to correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse would compare any findings to baseline findings to determine whether there were any changes.

Question 17

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?

A. Clear mentation
B. Minimal dyspnea
C. Oxygen saturation of 85%
D. Arterial oxygen level of 78 mm Hg (10.3 kPa)

Answer 17

A. Clear mentation

Rationale:
An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels would be 80 to 100 mm Hg (10.6 to 13.33 kPa). Oxygen saturation needs to be higher than 95%.

Question 18

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they would report which early symptom of compartment syndrome?

Cold, bluish-colored fingers
Numbness and tingling in the fingers
Pain that increases when the arm is dependent
Pain that is out of proportion to the severity of the fracture

Answer 18

Numbness and tingling in the fingers

Rationale:
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.

Question 19

A client with a hip fracture asks the nurse about Buck’s (extension) traction that is being applied before surgery and what is involved. The nurse would provide which information to the client?

Allows bony healing to begin before surgery and involves pins and screws

Provides rigid immobilization of the fracture site and involves pulleys and wheels

Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Answer 19

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Rationale:
Buck’s (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

Question 20

The nurse is preparing to teach a client with a leg cast applied to treat a fracture how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment would include which information?

The client’s fear related to the use of crutches
The client’s feelings about the restricted mobility
The client’s understanding of the need for increased mobility
The client’s vital signs, muscle strength, and previous activity level

Answer 20

The client’s vital signs, muscle strength, and previous activity level

Rationale:
Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine whether the client has enough strength for crutch walking and whether muscle-strengthening exercises are necessary. Previous activity level will provide information related to the tolerance of activity. The remaining options also are components of the assessment, but physiological needs take precedence over psychosocial needs.

Question 21

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed?

Use the assistance of four nurses to reposition the client.

Place a drawsheet on the mattress for pulling the client up in bed.

Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed.

Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning

Answer 21

Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed.

Rationale:
The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed frame for the client’s use. Although a drawsheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote repositioning by the client. Encouraging the client to push with the unaffected leg on the bed mattress for repositioning may cause skin breakdown on the unaffected heel area.

Question 22

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture would be included by the nurse in the client’s education?

Simple fracture
Greenstick fracture
Compound fracture
Comminuted fracture

Answer 22

Comminuted fracture

Rationale:
A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.

Question 23

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse would make which interpretation about this finding?

Arterial insufficiency
Impaired venous return
Impaired arterial circulation
The presence of an infection

Answer 23

Impaired venous return

Rationale:
Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of “hot spots,” which are areas of the cast that feel warmer to the touch than the rest of the cast.

Question 24

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)?

The client’s mobility status
The renal and endocrine systems
The cardiovascular and renal systems
The neurological and respiratory systems

Answer 24

The neurological and respiratory systems

Rationale:
The early signs of the complication of fat embolism include changes in the client’s mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client’s mobility status is unrelated to the signs of fat embolism.

Question 25

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings would be listed in the care plan as a sign/symptom of fat embolism?

Fever and chills
Dyspnea and chest pain
External rotation of the right leg
Pallor, paresthesia, and pulselessness of the right lower leg

Answer 25

Dyspnea and chest pain

Rationale:
The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment.

Question 26

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings would the nurse identify as early signs of possible fat embolism?

Decreased heart rate and increased restlessness
Decreased heart rate and decreased respiratory rate
Increased heart rate and adventitious breath sounds
Increased heart rate and increased oxygen saturation

Answer 26

Increased heart rate and adventitious breath sounds

Rationale:
Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The remaining options are incorrect.

Question 27

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action?

Elevate the casted leg.
Contact the primary health care provider.
Administer another dose of pain medication.
Check the neurovascular status of the toes on the casted leg.

Answer 27

Check the neurovascular status of the toes on the casted leg.

Rationale:
An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine whether the primary health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment.

Question 28

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse would suspect impairment with the neurovascular status of the client’s casted extremity if which findings are noted? Select all that apply.

Capillary refill less than 3 seconds
Pulses present and with swollen, pink fingers
Client report of severe, deep, unrelenting pain
Client report of pain as nurse assesses finger movement
Client report of numbness and tingling sensation in the fingers

Answer 28

Client report of severe, deep, unrelenting pain
Client report of pain as nurse assesses finger movement
Client report of numbness and tingling sensation in the fingers

Rationale:
The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.

Question 29

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what would the nurse plan to use as the most important item for this maneuver?

Bed pillow
Abductor splint
Adductor splint
Overhead trapeze

Answer 29

Abductor splint

Rationale:
After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.

Question 30

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply.

Ice
Heat
Analgesics
Muscle relaxers
Intermittent traction

Answer 30

Heat
Analgesics
Muscle relaxers
Intermittent traction

Rationale:
Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the primary health care provider’s preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.

Question 31

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information would the nurse include in the teaching?

“A bone fragment has injured the nerve supply in the area.”

“An injured artery caused impaired arterial perfusion through the compartment.”

“Bleeding and swelling caused increased pressure in an area that couldn’t expand.”

“The fascia expanded with injury, causing pressure on underlying nerves and muscles.”

Answer 31

“Bleeding and swelling caused increased pressure in an area that couldn’t expand.”

Rationale:
Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.

Question 32

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse would plan to use which method to reposition the client?

A trochanter roll to prevent abduction during turning
A pillow to keep the right leg abducted during turning
A pillow to keep the right leg adducted during turning
A trochanter roll to prevent external rotation during turning

Answer 32

A pillow to keep the right leg abducted during turning

Rationale:
After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client’s legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned.

Question 33

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information would the nurse include?

“You will use full weight bearing by discharge.”
“You will not be able to bear weight at all by discharge.”
“You will need to remain on bed rest even after discharge.”
“You will be able to bear some weight as tolerated with a walker or crutches by discharge.”

Answer 33

“You will be able to bear some weight as tolerated with a walker or crutches by discharge.”

Rationale:
After total knee arthroplasty, there is an emphasis on physical therapy as part of the plan of care. By discharge, the client should have adequate flexion in the operative knee for ambulation and will be able to bear some weight as tolerated with a walker or crutches. However, the surgeon’s prescriptions are always followed with regard to weight bearing. The other options are incorrect.

Question 34

A client has been placed in Buck’s extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action?

Using a footboard
Providing an overhead trapeze
Slightly elevating the foot of the bed
Slightly elevating the head of the bed

Answer 34

Slightly elevating the foot of the bed

Rationale:
The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Buck’s extension traction (which is applied to a leg), the foot of the bed is elevated. The remaining options are incorrect.

Question 35

The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction?

“I need to sit in my recliner when I get home.”
“I need to keep my legs apart while sitting or lying.”
“I would try to obtain an elevated toilet seat for use at home.”
“I need to contact the surgeon if the incision becomes red or irritated or if I note any drainage.”

Answer 35

“I need to sit in my recliner when I get home.”

Rationale:
After total hip replacement, the client needs to be instructed to sit on a high, firm chair. The client would be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The surgeon needs to be notified if the client notes the development of any redness, irritation, or drainage at the incision site.

Question 36

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client’s recent history?

Sprained left ankle
Decreased calcium intake
Open trauma to the left leg
Starting to smoke cigarettes

Answer 36

Open trauma to the left leg

Rationale:
Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.

Question 37

The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action?

Pulling up using the trapeze
Flexing and extending the feet
Doing quadriceps-setting and gluteal-setting exercises
Performing active range of motion to the right ankle and knee

Answer 37

Performing active range of motion to the right ankle and knee

Rationale:
Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (i.e., quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion.

Question 38

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse would inquire about the last time the client had which done?

Tuberculin test
Tetanus vaccine
Chest radiograph
Physical examination

Answer 38

Tetanus vaccine

Rationale:
With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.

Question 39

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse would plan to carefully monitor the client for which signs/symptoms?

Fever and bradycardia
Fever and hypertension
Tachycardia and hypotension
Bradycardia and hypertension

Answer 39

Tachycardia and hypotension

Rationale:
Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.

Question 40

A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse would assess which area as high risk for pressure and breakdown?

Left heel
Scapulae
Right heel
Back of the head

Answer 40

Left heel

Rationale:
Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. Scapulae and the back of the head are not common areas for pressure ulcers for this client. The right heel is elevated because of traction.

Question 41

The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse would perform which action?

Assess the client’s cognitive level.
Assess the temperature of the cast.
Monitor for the presence of drainage or odors on or beneath the cast.
Assess capillary refill, temperature, color, and amount of pain in the right hand.

Answer 41

Assess capillary refill, temperature, color, and amount of pain in the right hand.

Rationale:
The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.

Question 42

The nurse is caring for a client admitted for a fractured hip that was sustained from a fall at home. On assessment of the client’s affected lower extremity, which signs/symptoms would most likely be noted?

Shortening and abduction
Abduction and internal rotation
Shortening and internal rotation
Shortening and external rotation

Answer 42

Shortening and external rotation

Rationale:
Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.

Question 43

The nurse is caring for a client diagnosed with osteomyelitis from a skeletal injury. Which mechanism of the disease process can result in necrosis of the bone?

Devascularization
Infection of the bone
Decreased bone mass
Decreased bone density

Answer 43

Devascularization

Rationale:
Osteomyelitis is an infectious process affecting the bone, bone marrow, and surrounding soft tissue. A microorganism gains entry into the blood and grows, causing increased pressure on the bone, leading to ischemia and ultimately necrosis as a result of devascularization. Infection of the bone occurs but is not specifically related to necrosis of the bone. Decreased bone mass and decreased bone density are also not related to necrosis of the bone.

Question 44

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching?

“I can use the blunt part of a ruler to scratch the area.”
“I can trickle small amounts of water down inside the cast.”
“I need to obtain assistance when placing an object into the cast for the itching.”
“I can use a hair dryer on the low setting and allow the cool air to blow into the cast.”

Answer 44

“I can use a hair dryer on the low setting and allow the cool air to blow into the cast.”

Rationale:
Itching is a common complaint of clients with casts. Objects would not be put inside a cast because of the risk of scratching the skin, thereby providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.

Question 45

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions would the nurse include in the plan to prevent complications of the surgery? Select all that apply.

Keep the leg slightly abducted.
Teach leg exercises to the client.
Use aseptic technique for wound care.
Prevent hip flexion beyond 90 degrees.
Keep the client’s knees flexed whenever the client is in bed.
Massage the legs daily to increase circulation and venous return.

Answer 45

Keep the leg slightly abducted.
Teach leg exercises to the client.
Use aseptic technique for wound care.
Prevent hip flexion beyond 90 degrees.

Rationale:
A total hip arthroplasty (THA) is also known as a total hip replacement (THR). Postoperative complications can include dislocation, infection, venous thromboembolism, hypotension, bleeding, and infection. To prevent dislocation, the nurse needs to position the client correctly with the leg slightly abducted and prevent hip flexion beyond 90 degrees. Signs of dislocation such as acute pain, rotation, and extremity shortening need to be reported immediately to the surgeon. To prevent infection, the nurse needs to perform thorough hand washing and use aseptic technique for wound care and emptying of drains. To prevent venous thromboembolism, the client would wear elastic stockings and/or a sequential compression device per agency policy and surgeon prescription. The nurse would encourage fluid intake and teach the client leg exercises to promote circulation. Legs are not massaged; in addition, knee flexion is avoided for a prolonged period of time because these actions promote venous stasis and thromboembolism. The nurse would monitor vital signs at least every 4 hours and observe the client for bleeding. Any signs of complications are reported immediately to the surgeon.

Question 46

The nurse is assigned to care for a client who is in Buck’s traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan?

Make sure that the knots are at the pulleys.
Inspect the skin under the boot at least every 8 hours.
Make sure the head of the bed is kept at a 45- to 90-degree angle.
Monitor the weights to be sure that they are resting on a firm surface.

Answer 46

Inspect the skin under the boot at least every 8 hours.

Rationale:
When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device for skin irritation and breakdown. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

Question 47

The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client’s record are supportive of this diagnosis? Select all that apply.

Pyrexia
Elevated potassium level
Elevated white blood cell count
Elevated erythrocyte sedimentation rate
Bone scan impression indicative of infection

Answer 47

Pyrexia
Elevated white blood cell count
Elevated erythrocyte sedimentation rate
Bone scan impression indicative of infection

Rationale:
Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.

Question 48

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply.

Twisting of the spine
Curvature of the spine
Hyperflexion of the spine
Sciatic nerve inflammation
Degeneration of the facet joints
Herniation of an intervertebral disk

Answer 48

Twisting of the spine
Hyperflexion of the spine
Herniation of an intervertebral disk

Rationale:
Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.

Question 49

The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action would the nurse teach the client to avoid?

Crossing legs at the ankle
Using an elevated toilet seat
Placing a pillow between the legs
Keeping the legs abducted from the midline

Answer 49

Crossing legs at the ankle

Rationale:
Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times.

Question 50

The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction?

Bends over to tie shoes
Sits in a recliner with feet elevated
Squats to pick up an item from the floor
Sleeps in a side-lying position with knees and hips bent

Answer 50

Bends over to tie shoes

Rationale:
To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking things up or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.

Question 51

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention would the nurse plan to perform?

Apply ice to the affected area.
Perform sterile dressing changes.
Instruct the client on leg exercises.
Measure the leg circumference daily.

Answer 51

Perform sterile dressing change

Rationale:
Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; and fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg is not necessary.

Question 52

A client with a femur fracture develops fat embolus and is experiencing respiratory distress. The nurse plans to assist with which therapies?

Administration of plasma expanders, low-flow oxygen, and suctioning
Administration of bronchodilators, intubation, and mechanical ventilation
Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure
Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask

Answer 52

Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure

Question 53

The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action?

Reassess the vital signs.
Palpate bilateral peripheral pulses.
Perform a neurological assessment.
Position the client in a Fowler’s position.

Answer 53

Position the client in a Fowler’s position.

Rationale:
Clients with fractures are at risk for fat embolism. With suspected fat embolism, the nurse would position the client in a sitting (Fowler’s) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The primary healthcare provider needs to be notified. Vital signs will need to be taken, but this action may delay initial and required interventions. Peripheral pulse assessment is not a priority action. A neurological assessment needs to be performed, but this would not be the initial nursing action.

Question 54

The hospital code team is responding to a respiratory emergency of a client admitted during the night with a fractured hip and pelvis after a motor vehicle collision (MVC). The client first became confused and then developed dyspnea; chest pain; and a petechial rash on the neck, upper arms, and chest. What condition is this client at risk for?

Pulmonary fibrosis
Hypovolemic shock
Blood clot embolism
Fat embolism syndrome (FES)

Answer 54

Fat embolism syndrome (FES)

Rationale:
FES generally happens within 12 to 48 hours after a long bone, hip, or pelvis fracture and occurs most often in young men between ages 20 and 40 years and in older adults between ages 70 and 80. FES is a serious complication in which fat globules are released from the yellow bone marrow into the bloodstream and clog small blood vessels that supply vital organs, most commonly the lungs.