Chapter 50 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 50

Question 1

Type: MCSA

A patient who has been casted for a fracture of the left ulna asks the nurse when the cast will come off. The nurses response is based on the knowledge that the cast will be removed when which physiologic parameter has been met?

1. The remodeling phase of the bone healing process has been completed, allowing for application of mechanical stress.

2. A cartilage collar can be clearly felt at the site of the original break.

3. A specific amount of time has passed, predetermined by the severity of the break.

4. The X-ray of the fractured bone shows that the ends are well joined.

Correct Answer: 4

Rationale 1: Remodeling of the bone occurs after the cast is removed.

Rationale 2: During cellular proliferation and callus formation, a cartilage collar is evident around the fracture site, but this does not signify that the bone has healed sufficiently to remove the cast.

Rationale 3: While the amount of time a fracture requires casting varies, the severity of the fracture is only one factor that is considered.

Rationale 4: Ossification is the final laying down of bone after the fracture has been bridged and the fragments are united. Mature bone replaces the callus, and the fracture site feels firm and appears united on radiograph. It is at this point that a cast may be removed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-3

Question 2

Type: MCSA

A patient has a dislocated hip as the result of a fall. The nurse recognizes which primary reason to quickly return the femoral head to its normal position?

1. To preserve blood flow to the head of the femur

2. To avoid damage to nerves in the affected area

3. To minimize the damage to affected ligaments

4. To eliminate the severe pain the patient is experiencing

Correct Answer: 1

Rationale 1: A dislocation is a displacement of a bone from its normal position in a joint. While the dislocation requires reduction as soon as possible to reduce damage, the primary concern is interference with blood supply to the femoral head. This can lead to severe complications such as avascular necrosis (AVN).

Rationale 2: Damage to nerves in the affected area is a potential complication of dislocation. This is a serious situation but is not the highest priority.

Rationale 3: Damage to ligaments is a potential complication of dislocation. This is a serious situation but is not the highest priority.

Rationale 4: Pain occurs with dislocation. This is a serious situation but is not the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-4

Question 3

Type: MCMA

The nurse explains to a patient who is having a cast removed that the remodeling phase of fracture healing involves which changes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Creation of the cartilage collar at the fracture sight

2. Application of stress and weight to the affected bone

3. Granulation of new bone tissue to form the connective bridge

4. Resorption of excess new bone at the site of the callus

5. Strengthening of the new bone at the site of the fracture

Correct Answer: 2,4,5

Rationale 1: A cartilage collar does form, but not in the remodeling phase.

Rationale 2: The remodeling process is directed by mechanical stress and weight bearing, causing the bone to become stronger in relation to its function.

Rationale 3: Granulation is involved in the formation of a connective bridge, but this does not occur in the remodeling phase.

Rationale 4: The remodeling process involves resorption of the excess callus in the marrow space and the external aspect of the fracture.

Rationale 5: The remodeling process involves resorption of the excess callus in the marrow space and the external aspect of the fracture. The process is directed by mechanical stress and weight bearing, causing the bone to become stronger in relation to its function.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-3

Question 4

Type: MCMA

The nurse is caring for a patient whose fractured left femur was surgically managed with intramedullary (I-M) rodding. The nurse would explain which benefits of this type of fixation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It results in only minimal skin scarring.

2. It does not interfere with range of motion.

3. It facilitates direct visualization of the fracture.

4. It reduces the risk of a postsurgical fat embolus.

5. It allows for early weight bearing.

Correct Answer: 1,2,5

Rationale 1: The benefits of this fixation method include small surgical scars in less obvious places than with other methods.

Rationale 2: This fixation method leaves the joint free to move so there is less interference with range of motion.

Rationale 3: If direct visualization of the fracture is required, the open reduction method of repair is chosen.

Rationale 4: There is a slightly higher risk of fat embolism with this method.

Rationale 5: Intramedullary (I-M) rodding is a method of fracture fixation that entails sliding a metal rod down the medullary canal of a long bone. This form of fixation allows for early weight bearing because it shares the load.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 5

Type: MCSA

The nurse cannot palpate a patients pedal pulse following an open reduction internal fixation (ORIF) procedure for a fractured tibia. Which action is the priority intervention?

1. Check the lower extremity for pallor.

2. Notify the surgeon of the problem.

3. Assess the patients pain rating.

4. Use a Doppler to find the pedal pulse.

Correct Answer: 4

Rationale 1: Pallor is not the best indicator of circulation status.

Rationale 2: Notifying the surgeon, if indicated, should occur once all assessment data are collected.

Rationale 3: A pain rating is not the best indicator of circulation status.

Rationale 4: To assess the circulation when the pulse is not palpable, the nurse should use a Doppler.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 6

Type: MCMA

A patient is admitted after traumatic amputation of the left leg just below the knee. This crushing injury occurred at work while the patient was taking a smoking break. The nurse provides care based on which knowledge?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Crushing injuries are usually suitable for reattachment of the limb.

2. The patients report of pain in the area of the amputated foot is real.

3. Smoking is a significant risk factor for impaired healing of reattached limbs.

4. The recovery period for a limb reattachment would be similar to that for a surgical amputation.

5. Nerve regeneration to a reattached lower limb usually results in poor function.

Correct Answer: 2,3,5

Rationale 1: Reattachment in crush-type amputations is not attempted due to the poor outcome.

Rationale 2: The patient may have bizarre sensations, such as feeling as if the absent foot is cold or itchy. These are called phantom limb sensations.

Rationale 3: Reattachment may not be attempted in patients who smoke because of the risk of impaired healing.

Rationale 4: Complete amputation and prosthesis could allow a patient to return to normal activities in days to weeks, whereas reconstruction of mangled limbs can span years, with a huge psychological strain and impact on function and occupation.

Rationale 5: Surgical reattachment of a severed limb is done only under certain circumstances because the surgery is difficult. For adults, it is nearly impossible for nerves to regenerate in the lower extremity, and the reattached limb may be painful and dysfunctional.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-4

Question 7

Type:

MCSA

A patient wearing a long leg cast has assessment findings of compartment syndrome in the extremity. The nurse demonstrates understanding of the complication and its specific treatment by gathering which equipment?

1. Pillows to elevate the leg

2. A percussion hammer

3. Bucks traction equipment

4. Ace bandages

Correct Answer: 4

Rationale 1: Elevating the leg above the heart would compromise circulation.

Rationale 2: At this point the diagnosis has been made; further assessment is not indicated and would waste time.

Rationale 3: Bucks traction is not a priority in the current care of this patient.

Rationale 4: Compartment syndrome occurs when excess pressure in a limited space constricts the structures within a compartment, reducing circulation to muscles and nerves. With increased edema, this event threatens the viability of the limb and increases the risk of sepsis. Treatment can include removing the cast entirely or bivalving it (splitting it apart with a cast cutter) and securing the two sides with Ace wraps, tape, or Velcro straps.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-4

Question 8

Type: MCSA

A committee of musculoskeletal care nurses has been meeting to formulate policy changes regarding the proper method for providing pin site care. Based on current research findings, the nurses come to which conclusion?

1. The critical period for infection control measures is up to 48 hours out from pin insertion.

2. Pins located in areas of considerable soft tissue are at lowest risk for infection.

3. Chlorhexidine 2 mg/mL solution is the cleanser of choice.

4. Hydrogen peroxide is an acceptable skin cleanser.

Correct Answer: 3

Rationale 1: The critical period for infection control is after the first 48 to 72 hours, when drainage may be heavy; pin site care should be done daily.

Rationale 2: Pins located in areas with considerable soft tissue should be considered at greater risk for infection.

Rationale 3: Research supports that chlorhexidine 2 mg/mL solution is the most effective cleansing solution for pin site care.

Rationale 4: The use of hydrogen peroxide is discouraged because it may cause damage to the healthy tissue surrounding the pin; it has also been associated with increased infection rates and the disruption of the skins normal flora.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 9

Type: MCSA

Which findings would indicate possible compromise of ulnar nerve integrity following surgical repair of a patients elbow?

1. Edema in the forearm that is rated 3+

2. Pain radiating from the wrist to the middle finger

3. Inability to make the OK sign by bringing the thumb to the fourth or fifth finger

4. Slight flexion limitation (less than 15 degrees) during passive ROM

Correct Answer: 3

Rationale 1: Edema in the forearm rated at 3+ is a symptom of impaired circulation above the site of the edema, either from a tight dressing or cast; it is not a symptom of compromised ulnar integrity.

Rationale 2: Numbness in the ring and pinkie fingers is a symptom of compartment syndrome that would occur with compromise of the ulnar nerve. Radiating pain from the wrist to the middle finger would not be an expected finding.

Rationale 3: Compression from bleeding or severe swelling at the ulnar nerve would not allow the finger and thumb to be brought together without severe pain.

Rationale 4: Slight flexion limitations are a symptom of musculoskeletal shortening that comes with disuse and are not a symptom related to ulnar integrity changes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 50-2

Question 10

Type: MCSA

The nurse would immediately report to the surgeon which finding in a patient who had a total knee replacement within the last 24 hours?

1. Diminished sensations in both legs and feet

2. Motor strength of 4 in the unaffected leg

3. Capillary refill time of 5 seconds in the toes of the surgical leg

4. Slight pallor and skin coolness bilaterally

Correct Answer: 3

Rationale 1: Diminished sensation in both legs is a reflection of prolonged neurovascular changes and should be compared to the presurgical status; it is probably not related to the surgery itself and immediate notification is not required.

Rationale 2: Motor strength of 4 in the unaffected leg does not require immediate notification of the health care provider; it is probably not related to the surgery.

Rationale 3: A capillary refill time of less than 3 seconds is considered normal. It is prolonged in this patient, which might indicate compromised arterial flow in the surgical leg, and notification is necessary.

Rationale 4: Pallor and cool skin temperature can reflect arterial flow decreases, but in this patient it is bilateral. This finding needs further investigation, but it is not urgent and probably not related to the surgery itself.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-2

Question 11

Type: MCSA

The nurse would recognize the need for additional teaching in a patient after posterior hip replacement when observing which activity?

1. The patient uses an abductor pillow while in bed.

2. The patient uses a regular-height toilet seat.

3. The patient keeps the affected leg and foot turned upright while in bed.

4. The patient keeps the operative leg straight when getting out of bed and uses the arms to push up out of bed.

Correct Answer: 2

Rationale 1: An abductor pillow is required to keep the hip in proper alignment and prevent it from popping out of place.

Rationale 2: The toilet seat height needs to be raised to prevent overextension of the hip joint. Additional teaching is needed to prevent

complications from the posterior hip replacement.

Rationale 3: An upright position keeps the leg and hip in proper alignment to prevent displacement; the leg is not turned inward for the same reason.

Rationale 4: Keeping the leg straight and using the arms prevent displacement from twisting the hip when getting out of bed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 50-5

Question 12

Type: MCSA

Following hip replacement surgery, which patient statement would the nurse evaluate as indicating additional teaching is necessary?

1. I will sit down in a chair to reach items below waist height.

2. I will use a shower chair and raised toilet seat when performing hygiene.

3. My husband has removed our loose carpets and has cleared out our walkway.

4. My daughter bought me a reacher to access things on the floor.

Correct Answer: 1

Rationale 1: Sitting in a chair and trying to reach below waist level places the hip at a flexion angle of more than 90 degrees. Dislocation is possible.

Rationale 2: A shower chair and raised toilet seat keep the hips at the correct angle to prevent displacement.

Rationale 3: Loose carpets and objects in walkways may cause falls and further injure the patient and/or the hip replacement itself.

Rationale 4: Using a reacher will prevent bending or stooping that might cause hip displacement.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 50-5

Question 13

Type: MCSA

Assessment of a patient postarthroplasty reveals tachypnea, air hunger, hypoxia, O2 sat of 86%, declining mental status, and petechiae. What is the nurses priority action?

1. Apply oxygen at 3 to 4 liters /minute.

2. Call a code for potential cardiac arrest.

3. Prepare the patient for immediate intubation and mechanical ventilation with PEEP.

4. Raise the head of the bed (HOB) and encourage coughing every hour.

Correct Answer: 3

Rationale 1: Application of oxygen would improve the availability of oxygen within the lungs but would not improve the perfusion at the alveolar capillary membrane.

Rationale 2: Calling for a code related to cardiac arrest is not appropriate at this time because the heart is not the problem; the pulmonary status should be addressed first.

Rationale 3: The symptoms are related to severely compromised pulmonary status, probably acute respiratory distress syndrome (ARDS), which is related to a fat embolus blocking the pulmonary vessel and inactivating surfactant. Intubation and mechanical ventilation with PEEP (positive end-expiratory pressure) are needed to maximize air exchange and treat symptoms until the condition resolves.

Rationale 4: Raising the HOB will improve gas exchange slightly, but the problem is not expansion of the chest, so the condition will not improve.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 14

Type: MCSA

A patient experienced a cerebral spinal fluid leak after spinal surgery. The leak has just been treated with a blood patch. What is the nurses priority action?

1. Administering a bolus of IV fluids

2. Positioning the patient on the left side

3. Initiating strict isolation procedures

4. Keeping the patient flat in bed for 2 hours

Correct Answer: 4

Rationale 1: Administration of increased fluids is not indicated. Rapid fluid administration could increase the cerebral spinal pressure and increase the risk of rupture of the patch.

Rationale 2: Positioning the patient on the left side is not indicated.

Rationale 3: Sterile procedures and sterile dressings should minimize the risk of infection. Strict isolation procedures are not indicated.

Rationale 4: Keeping the patient flat in bed for 2 hours will allow the blood patch to clot and not migrate to other parts of the spine, thus allowing a seal to be formed to minimize/stop the leaking of cerebral spinal fluids.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 15

Type: MCSA

A patient has had hip replacement surgery. What is the nurses best plan to address this patients ambulation needs?

1. Keep both bed rails up at all times so the patient will not attempt ambulation without assistance.

2. Teach the patient how to use a walker.

3. Have the patient practice log-rolling to the side of the bed before getting up.

4. Have the patient use a wheelchair until the hip is completely healed.

Correct Answer: 2

Rationale 1: Keeping both bed rails up can be construed as enforcing a restrictive environment and is not the best option.

Rationale 2: A walker provides stable support to prevent falling injuries. The ability to bear weight on the surgical leg varies, based on the type of surgery performed, but a walker gives a more stable base than a cane or crutch assistive device.

Rationale 3: The patient should not log-roll as this may cause hip dislocation.

Rationale 4: The patient will start walking very early in recovery. A wheelchair is needed only if the patient must travel long distances.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-6

Question 16

Type: MCSA

A patient with carpal tunnel syndrome is being treated conservatively. Which information would the nurse provide?

1. Your wrist will be casted for the first 3 weeks, followed by a protective splint for the next 6 to 8 weeks.

2. Exercise your wrist for complete rotation and ROM every 4 hours while awake.

3. Wear a brace or wrist splint at night and during activities that aggravate the symptoms.

4. Wear an external hinge splint to support the wrist for several months.

Correct Answer: 3

Rationale 1: Wearing a cast for several weeks followed by a sprint applies to wrist arthroplasty, not endoscopic carpal tunnel release.

Rationale 2: Exercising the wrist will increase strain and cause more swelling that will delay the healing process.

Rationale 3: Wearing a brace or splint will keep the wrist in a natural position during sleep and will offer support during activities that aggravate the symptoms.

Rationale 4: A hinge splint is designed for elbow surgery, not for carpal tunnel syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-6

Question 17

Type: MCSA

Which nursing intervention would be included in pain management of a patient after orthopedic surgery?

1. Administering pain medications only when the patient is awake

2. Anticipatory pain management prior to therapy

3. Assessing vital signs to evaluate the degree of pain

4. Encourage the patient to lengthen the time intervals between pain medication doses.

Correct Answer: 2

Rationale 1: Pain medications should be given around the clock for more effective management of pain at all times.

Rationale 2: Anticipatory pain management will improve the efforts during therapy to speed up the recovery process. Better pain management that is more consistently given will improve outcomes of recovery and patient satisfaction.

Rationale 3: Vital signs do not always reflect the degree of pain experienced by the patient.

Rationale 4: The nurse should treat the pain to prevent pain-related complications. Encouraging the patient to lengthen the time between doses of pain medication is not good practice.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-7

Question 18

Type: MCSA

Which statement by an adolescent patient recovering from a sprain would indicate the need for further instruction by the nurse regarding care at home?

1. I should put a heating pad on my leg as soon as I get home.

2. I should avoid weight bearing on this leg for a couple days.

3. I should make sure to keep the Ace bandage on my leg.

4. I should prop this leg up when Im sitting in a chair.

Correct Answer: 1

Rationale 1: RICE (rest, ice, compression, elevation) is a recommended therapy for treating soft tissue trauma. These interventions allow the injured muscle, ligament, or tendon to heal (rest), cause vasoconstriction and reduce pain (ice), reduce edema formation (compression), and reduce edema and pain (elevation). Planning to use a heating pad would indicate the need for additional instruction by the nurse.

Rationale 2: Interventions should allow the injured muscle, ligament, or tendon to heal (rest). This therapy should be used for 24 to 48 hours.

Rationale 3: Interventions to reduce edema formation will be necessary for 24 to 48 hours.

Rationale 4: Interventions to reduce edema and pain should be used for 24 to 48 hours.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 50-4

Question 19

Type: MCSA

The nurse is planning care for a patient who had an above-the-knee amputation 2 days ago. Which position should the nurse include in this patients plan of care?

1. Sims position as tolerated

2. Flat in bed

3. High Fowlers position with the stump elevated

4. Sitting in a chair while awake

Correct Answer: 2

Rationale 1: Sims position is side-lying and would likely be uncomfortable for the patient.

Rationale 2: Lying flat in bed keeps the hip extended, which helps to prevent contracture.

Rationale 3: After 24 hours, the stump should not be elevated.

Rationale 4: Sitting in a chair for prolonged periods can lead to hip contracture.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-4

Question 20

Type: MCMA

The nurse is caring for a patient who has a grade II open fracture of the humerus. The nurse plans care for this patient based on which understanding?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Some crushing of the bone has occurred.

2. Major vascular reconstruction will be required.

3. There is a moderately high risk for developing an infection.

4. The patient has an inside-out fracture.

5. An inspection and debridement (I&D) procedure will be required.

Correct Answer: 1,3,5

Rationale 1: A grade II open fracture has a moderately contaminated wound bed and contains a moderate amount of comminution (bone fragments).

Rationale 2: If major vascular reconstruction is required, grade III is assigned.

Rationale 3: All open fractures have the potential to be contaminated, thus increasing the risk of infection.

Rationale 4: A grade I open fracture is sometimes referred to as an inside-out fracture.

Rationale 5: The wound requires a procedure to wash out the contamination; this is commonly referred to as an inspection and debridement (I&D).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-4

Question 21

Type: MCMA

The nurse is aware that which occupations could put a patient at risk for carpal tunnel syndrome?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Wheat farmer

2. Store cashier

3. Barber

4. Computer data input specialist

5. Carpenter

Correct Answer: 2,3,4,5

Rationale 1: The normal activities of wheat farming would be unlikely to put the farmer at risk for carpal tunnel syndrome.

Rationale 2: Repetitive hand motions are required for this profession, which increases the risk for carpal tunnel syndrome.

Rationale 3: Repetitive hand motions are required for this profession, which increases the risk for carpal tunnel syndrome.

Rationale 4: Repetitive hand motions are required for this profession, which increases the risk for carpal tunnel syndrome.

Rationale 5: Repetitive hand motions are required for this profession, which increases the risk for carpal tunnel syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-1

Question 22

Type: MCSA

A patient is diagnosed with a compound fracture and is scheduled for immediate surgery. Which nursing diagnosis would have the highest priority in the immediate postoperative period?

1. Impaired Transfer Ability

2. Risk for Post-Trauma Syndrome

3. Risk for Infection

4. Risk for Falls

Correct Answer: 3

Rationale 1: The patient may have difficulty with transfers, but this is not the greatest priority.

Rationale 2: Depending on the reason for the injury and the patients response, post-trauma syndrome may be applicable. This is not the greatest priority.

Rationale 3: The patient with an open, compound fracture has multiple bone breaks penetrating through the skin and must be assessed and cared for vigilantly for signs of infection.

Rationale 4: The patient is at risk for a fall due to fracture, but this is not the highest priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 50-4

Question 23

Type: MCMA

The nurse should assess a patient with a long leg cast for which signs that would indicate compromised circulation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Swelling of the toes

2. Drainage on the cast

3. Elevated temperature

4. Foul odor

5. A tight cast

Correct Answer: 1,5

Rationale 1: Swelling of the toes is likely due to decreased venous return caused by the cast being too tight.

Rationale 2: Drainage may indicate bleeding or infection.

Rationale 3: An elevated temperature indicates infection.

Rationale 4: Foul odor indicates an infective process.

Rationale 5: Edema can cause the cast to become tight. A tight-fitting cast can lead to compartment syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-4

Question 24

Type: MCSA

A patient is diagnosed with a sprained right ankle. The nurse instructs the patient on which common treatment of sprains?

1. Application of a long leg cast

2. Opioid pain medication

3. Heat, rest, compression, and elevation

4. Rest, ice, compression, and elevation

Correct Answer: 4

Rationale 1: Sprains are not treated with casts.

Rationale 2: Anti-inflammatory medications are best for sprains. Opioids are generally not required.

Rationale 3: Heat is contraindicated for treatment of sprains as it may increase swelling and pain.

Rationale 4: The interventions included in RICE therapy allow the injured muscle, ligament, or tendon to heal (rest), cause vasoconstriction and reduce pain (ice), decrease edema formation and pain (compression), and promote venous return to decrease edema and pain (elevation).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 25

Type: SEQ

The patient is diagnosed with an oblique fracture of the left femur. The nurse understands that the process of bone healing occurs in phases. Place in order the phases of the bone healing process.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Reparative phase

Choice 2. Initial injury (fracture)

Choice 3. Inflammatory phase

Choice 4. Remodeling phase

Correct Answer: 2,3,1,4

Rationale 1: Calcium is deposited during the inflammatory phase and a callus forms in the reparative phase. Collagen forms and calcium deposition continues.

Rationale 2: The bone healing process begins after the initial injury or fracture.

Rationale 3: The bleeding and inflammation that develop at the site of the fracture initiate the inflammatory phase.

Rationale 4: During the remodeling phase, excess callus is removed and new bone is laid down along the fracture line. The fracture site calcifies and the bone reunites.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-3

Question 26

Type: MCMA

Which assessment data would the nurse interpret as indicating a patient could be experiencing a fat embolus?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pulse oximetry 86%

2. Petechiae on the chest and upper arms

3. Shortness of breath and chest pain

4. Respiratory rate 32

5. Skin hot, dry, and flushed

Correct Answer: 1,2,3,4

Rationale 1: Hypoxemia is one of the classic findings associated with fat embolism syndrome.

Rationale 2: Petechial rash is a late manifestation of fat embolism syndrome.

Rationale 3: Dyspnea is an early finding of fat embolism syndrome.

Rationale 4: Tachypnea is an early finding of fat embolism syndrome.

Rationale 5: Hot, dry, and flushed skin may indicate other pathology but is not associated with fat embolism syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-2

Question 27

Type: MCSA

A patient recovering from a fractured hip is at risk for developing deep vein thrombosis (DVT). The nurse monitors for which findings that would indicate DVT is occurring?

1. Positive Homans sign

2. Decreased urine output

3. Confusion

4. Tachypnea

Correct Answer: 1

Rationale 1: Homans sign is considered positive when plantar and dorsiflexion on the affected side cause calf pain. A positive Homans is considered a sign of possible DVT.

Rationale 2: Dehydration may cause DVT, but decreased urine output alone would not be a reason to suspect DVT.

Rationale 3: Confusion is not a sign of DVT, but it may indicate that venous thromboembolism has occurred from a DVT.

Rationale 4: Tachypnea is not a sign of DVT, but it may indicate that venous thromboembolism has occurred from a DVT.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-2

Question 28

Type: MCSA

The nurse is changing a patients stump dressing. How would the nurse document this dressing technique?

1. Figure-of-eight bandage

2. Binder wrapping

3. Splinting

4. Bivalving

Correct Answer: 1

Rationale 1: Compression wrapping of the extremity helps to prevent edema. Figure-of-eight bandaging starts at the distal stump (after the bandage is anchored around the waist) and is wrapped back toward the waist.

Rationale 2: This bandage is not applied like a binder.

Rationale 3: No splint is used in this technique.

Rationale 4: Bivalving of a cast is used to reduce the risk of compartment syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 29

Type: MCSA

The patient has a fracture of the right tibia and fibula. The orthopedic surgeon decides to surgically correct the fractures with the type of device pictured in the figure. What type of device is being used?

1. External fixation device

2. Internal fixation device

3. Bucks traction

4. External wiring

Correct Answer: 1

Rationale 1: In external fixation, pins are placed through the bone above and below the fracture site to attach the bone to an external frame.

Rationale 2: Internal fixation devices involve a surgical incision with the placement of plates and screws. The incision is then closed and the devices are not visible externally.

Rationale 3: Bucks traction is a traction device used for fractured hips.

Rationale 4: This is not a wiring device.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 30

Type: MCMA

The nurse has identified the diagnosis Acute Pain for a patient recovering from an above-the-knee amputation. Which nursing interventions would be beneficial for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer analgesics before pain reaches a higher level.

2. Support the injured area when moving the patient.

3. Elevate the stump on three pillows.

4. Encourage deep breathing and relaxation exercise.

5. Reposition the patient every 8 hours.

Correct Answer: 1,2,4

Rationale 1: Analgesics alleviate pain by stimulating opiate receptor sites. If pain medication is given when pain is rated at a lower level, the pain will be managed more effectively.

Rationale 2: Supporting the injured area reduces pain when the patient is moving.

Rationale 3: Elevating the stump can increase the risk of hip contractures.

Rationale 4: Encouraging deep breathing and relaxation will increase the effectiveness of analgesics and modify the pain.

Rationale 5: The patient should be repositioned every 2 hours to prevent muscle cramping and prolonged pressure on any area.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 50-7

Question 31

Type: MCMA

The nurse is teaching older adults about the risks for musculoskeletal trauma. Which strategies should the nurse include?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid falls at home by not using throw rugs.

2. Maintain good nutrition.

3. Be screened for osteoporosis.

4. Avoid crowds.

5. Use assistive devices as necessary.

Correct Answer: 1,2,3,5

Rationale 1: Throw rugs, cords, and other objects that impinge on traffic areas increase the risk of falls at home for older adults.

Rationale 2: The older patient should maintain good nutrition. Nutrition evaluation may be necessary.

Rationale 3: Screening for osteoporosis is an important health promotion activity for the older adult.

Rationale 4: There is no reason for older adults to avoid crowds. The older adult benefits from social stimulation.

Rationale 5: Some patients avoid using assistive devices because they are afraid they make them look old.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-1

Question 32

Type: MCMA

The nurse would be most alert for assessment findings of osteomyelitis in which patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient with a compound fracture

2. A patient who required open reduction of a fractured ankle

3. A patient who has a spiral fracture

4. A patient whose fractured radius was repaired with an external fixator device

5. A patient who has a torn anterior cruciate ligament

Correct Answer: 1,2,4

Rationale 1: Because the skin integrity has been interrupted, patients who have a compound fracture are at risk for development of osteomyelitis.

Rationale 2: Patients who have open orthopedic procedures are at risk for development of osteomyelitis.

Rationale 3: A spiral fracture does not increase risk for osteomyelitis.

Rationale 4: Because the external fixator device requires that pins be attached both to the bone and to an external frame, the patient is at risk for osteomyelitis.

Rationale 5: Tearing a ligament does not increase the risk for osteomyelitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-2

Question 33

Type: MCSA

A patient has a minor orthopedic injury to the arm. The nurse would suspect the development of complex regional pain syndrome (CRPS) based on which assessment findings?

1. The patient complains of widespread pain and has limited joint mobility.

2. The patient has a fever and a rash over the injured area.

3. The patient complains of vague abdominal pain with diarrhea.

4. The patients fingers are cyanotic.

Correct Answer: 1

Rationale 1: Diffuse pain and altered mobility after a local injury are findings associated with CRPS.

Rationale 2: Fever and rash are not associated with CRPS.

Rationale 3: Abdominal pain and diarrhea are not associated with CRPS.

Rationale 4: Cyanosis of the fingertips is not associated with CRPS.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 50-2

Question 34

Type: MCSA

Which home care instructions would the nurse provide a patient whose ulnar fracture was treated with an external fixator device?

1. Notify your health care provider if the pin sites become painful.

2. Adjust the tension on the pins if they feel too tight.

3. You may resume tub bathing after your pins have been in place for 5 days.

4. Try to avoid using the affected arm.

Correct Answer: 1

Rationale 1: New pain at the pin sites may indicate infection.

Rationale 2: The patient is not directed to adjust tension on the pins.

Rationale 3: Bathing (soaking in water) in a tub will not be permitted due to the chance of infection through pin sites.

Rationale 4: An external fixator is meant to increase the patients independence while maintaining immobilization.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 50-4

Question 35

Type: MCSA

The nurse is observing a patient learning to use crutches. Which observation would prompt the nurse to reinforce teaching about crutch walking?

1. The axillary crutches have been sized so they do not touch the patients axilla.

2. The patient using axillary crutches places the weight on the palms of the hands when walking.

3. The cuff of the patients forearm crutch fits just above the elbow.

4. The patient places only part of the weight on forearm crutches.

Correct Answer: 3

Rationale 1: Crutches should not touch the axilla but should be four finger widths below the axilla.

Rationale 2: The patients weight should be carried on the palms of the hands, not the axilla.

Rationale 3: The cuff of a forearm crutch should fit just below the elbow.

Rationale 4: Forearm crutches are not designed to carry all of the bodys weight.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 50-6

 

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