Chapter 63: Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 63: Nursing Management: Musculoskeletal Trauma and Orthopedic Surgery

Test Bank

MULTIPLE CHOICE

1. When counseling an older patient about ways to prevent fractures, which information will the nurse include?

a.

Tack down scatter rugs in the home.

b.

Most falls happen outside the home.

c.

Buy shoes that provide good support and are comfortable to wear.

d.

Range-of-motion exercises should be taught by a physical therapist.

ANS: C

Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

DIF: Cognitive Level: Application REF: 1586

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

2. A checkout clerk in a grocery store has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about

a.

surgical options.

b.

elbow injections.

c.

utilization of a left wrist splint.

d.

modifications in arm movement.

ANS: D

Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

DIF: Cognitive Level: Application REF: 1588-1589 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

3. When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to

a.

do stretching and warm-up exercises before starting work.

b.

wrap the wrists with a compression bandage every morning.

c.

use acetaminophen (Tylenol) instead of nonsteroidal anti-inflammatory drugs (NSAIDs) for wrist pain.

d.

obtain a keyboard pad to support the wrist while word processing.

ANS: D

Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.

DIF: Cognitive Level: Application REF: 1589-1590

TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

4. Which information will the nurse include when discharging a patient with a sprained wrist from the emergency department?

a.

Keep the wrist loosely wrapped with gauze.

b.

Apply a heating pad to reduce muscle spasms.

c.

Use pillows to elevate the arm above the heart.

d.

Gently move the wrist through the range of motion.

ANS: C

Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.

DIF: Cognitive Level: Application REF: 1587-1588

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

a.

You have an appointment with a physical therapist for tomorrow.

b.

You can still play baseball but you will not be able to return to pitching.

c.

The doctor will use the drop-arm test to determine the success of surgery.

d.

Leave the shoulder immobilizer on for the first few days to minimize pain.

ANS: A

Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent frozen shoulder. A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

DIF: Cognitive Level: Application REF: 1590-1591 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

6. A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place

a.

for several months.

b.

for at least 3 weeks.

c.

until swelling of the wrist has resolved.

d.

until x-rays show complete bony union.

ANS: B

Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

DIF: Cognitive Level: Application REF: 1593-1594

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

7. A patient with a comminuted fracture of the right femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should

a.

loosen the traction and have the patient turn onto the unaffected side.

b.

place a pillow between the patients legs and turn gently to each side.

c.

turn the patient partially to each side with the assistance of another nurse.

d.

have the patient lift the buttocks by bending and pushing with the left leg.

ANS: D

The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

DIF: Cognitive Level: Application REF: 1594-1595 | 1601 |1603

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

8. After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care?

a.

Avoid placing the patient in the prone position.

b.

Use the cast support bar to reposition the patient.

c.

Ask the patient about any abdominal discomfort or nausea.

d.

Discuss the reasons for remaining on bed rest for several weeks.

ANS: C

Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

DIF: Cognitive Level: Application REF: 1595-1597 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should

a.

keep the left arm in a dependent position.

b.

handle the cast with the palms of the hands.

c.

place gauze around the cast edge to pad any roughness.

d.

cover the cast with a small blanket to absorb the dampness.

ANS: B

Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

DIF: Cognitive Level: Application REF: 1595

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurses discharge teaching?

a.

I can get the cast wet as long as I dry it right away with a hair dryer.

b.

I should avoid moving my fingers and elbow until the cast is removed.

c.

I will apply an ice pack to the cast over the fracture site for the next 24 hours.

d.

I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.

ANS: C

Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

DIF: Cognitive Level: Application REF: 1595 | 1601 | 1603

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

11. Which of the following observations made by the nurse who is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg indicates that the patient can safely ambulate independently?

a.

The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

b.

The patient advances the right leg and both crutches together and then advances the left leg.

c.

The patient moves the left crutch with the left leg and then the right crutch with the right leg.

d.

The patient uses the bedside chair to assist in balance as needed when ambulating in the room.

ANS: B

When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

DIF: Cognitive Level: Application REF: 1604 TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

12. A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?

a.

Notify the health care provider.

b.

Assess the incision for redness.

c.

Reposition the left leg on pillows.

d.

Check the patients blood pressure.

ANS: A

The patients clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

DIF: Cognitive Level: Application REF: 1605-1606

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider?

a.

The patient states that the pelvis feels unstable.

b.

Abdominal distention is present and bowel tones are absent.

c.

There are ecchymoses on the abdomen and hips.

d.

The patient complains of pelvic pain with palpation.

ANS: B

The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

DIF: Cognitive Level: Application REF: 1607

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a patient who has an intracapsular fracture of the left femur?

a.

Assess for hip contractures.

b.

Monitor for hip dislocation.

c.

Check the peripheral pulses.

d.

Ask about left hip pain level.

ANS: D

Bucks traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Bucks traction.

DIF: Cognitive Level: Application REF: 1607-1608 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

15. A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching?

a.

You will need to assess and clean the pin insertion sites daily.

b.

The external fixator can be removed during the bath or shower.

c.

You will need to remain on bed rest until bone healing is complete.

d.

Prophylactic antibiotics are used until the external fixator is removed.

ANS: A

Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

DIF: Cognitive Level: Application REF: 1596-1597

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take?

a.

Use a mechanical lift to transfer the patient from the bed to the chair.

b.

Check the postoperative orders for the patients weight-bearing status.

c.

Avoid administration of pain medications before getting the patient up.

d.

Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

ANS: B

The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

DIF: Cognitive Level: Application REF: 1604

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about

a.

when and how to cut the immobilizing wires.

b.

self-administration of nasogastric tube feedings.

c.

the use of sterile technique for dressing changes.

d.

the importance of including high-fiber foods in the diet.

ANS: A

The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

DIF: Cognitive Level: Application REF: 1612-1613

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, If they want to cut off my foot, they should just shoot me instead. Which response by the nurse is best?

a.

Many people are able to function normally with a foot prosthesis.

b.

I understand that you are upset, but you may lose the foot anyway.

c.

Tell me what you know about what your options for treatment are.

d.

If you do not want the surgery, you do not have to have an amputation.

ANS: C

The initial nursing action should be to assess the patients knowledge level and feelings about the options available. Discussion about the patients option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patients current level of knowledge and emotional state.

DIF: Cognitive Level: Application REF: 1614

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19. On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take?

a.

Explain the reasons for the phantom limb pain.

b.

Administer prescribed analgesics to relieve the pain.

c.

Loosen the compression bandage to decrease incisional pressure.

d.

Remind the patient that this phantom pain will diminish over time.

ANS: B

Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

DIF: Cognitive Level: Comprehension REF: 1613-1614

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

20. Which statement by a patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective?

a.

I should lay on my abdomen for 30 minutes 3 or 4 times a day.

b.

I should elevate my residual limb on a pillow 2 or 3 times a day.

c.

I should change the limb sock when it becomes soiled or stretched out.

d.

I should use lotion on the stump to prevent drying and cracking of the skin.

ANS: A

The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

DIF: Cognitive Level: Application REF: 1614-1615 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

21. A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. A statement by the patient that indicates a need for additional discharge instructions is

a.

I should not cross my legs while sitting.

b.

I will use a toilet elevator on the toilet seat.

c.

I will have someone else put on my shoes and socks.

d.

I can sleep in any position that is comfortable for me.

ANS: D

The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

DIF: Cognitive Level: Application REF: 1608-1609 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

22. Which nursing action will the nurse include in the plan of care for a patient who has had a total knee arthroplasty?

a.

Avoid extension of the knee beyond 120 degrees.

b.

Use a compression bandage to keep the knee flexed.

c.

Start progressive knee exercises to obtain 90-degree flexion.

d.

Teach about the need to avoid weight bearing for 4 weeks.

ANS: C

After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

DIF: Cognitive Level: Application REF: 1618 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

23. A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery?

a.

I will be able to use my fingers to grasp objects better.

b.

I will not have to do as many hand exercises after the surgery.

c.

This procedure will prevent further deformity in my hands and fingers.

d.

My fingers will appear more normal in size and shape after this surgery.

ANS: A

The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

DIF: Cognitive Level: Application REF: 1618 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

24. When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include?

a.

Keep the hand immobile to prevent soft tissue swelling.

b.

Keep the right shoulder elevated on a pillow or cushion.

c.

Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury.

d.

Call the health care provider for increased swelling or numbness.

ANS: D

Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling.

NSAIDs are appropriate to treat pain after a fracture.

DIF: Cognitive Level: Application REF: 1603-1604

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

25. A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care?

a.

Use surgical net dressing to hang the arm from an IV pole.

b.

Immobilize the fingers on the left hand with gauze dressings.

c.

Assess the left axilla and change absorbent dressings as needed.

d.

Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C

The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

DIF: Cognitive Level: Application REF: 1595-1596 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

26. A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse?

a.

The patient uses crutches with a swing-to gait.

b.

The patient leans over to pull shoes and socks on.

c.

The patient sits straight up on the edge of the bed.

d.

The patient bends over the sink while brushing the teeth.

ANS: B

Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

DIF: Cognitive Level: Application REF: 1609

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

27. A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first?

a.

Stay with the patient and offer reassurance.

b.

Administer the prescribed PRN oxygen at 4 L/min.

c.

Check the patients legs for swelling or tenderness.

d.

Notify the health care provider about the symptoms.

ANS: B

The patients clinical manifestations and history are consistent with a pulmonary embolus, and the nurses first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

DIF: Cognitive Level: Application REF: 1605-1606

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

28. A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider?

a.

There is bruising at the shoulder area.

b.

The right arm appears shorter than the left.

c.

There is decreased range of motion of the shoulder.

d.

The patient is complaining of arm and shoulder pain.

ANS: B

A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

DIF: Cognitive Level: Application REF: 1588

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

29. A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of these prescribed collaborative interventions will the nurse implement first?

a.

Wrap the ankle and apply an ice pack.

b.

Administer naproxen (Naprosyn) 500 mg PO.

c.

Give acetaminophen with codeine (Tylenol #3).

d.

Take the patient to the radiology department for x-rays.

ANS: A

Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

DIF: Cognitive Level: Application REF: 1587-1588

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

30. When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)?

a.

Teach quadriceps-setting exercises.

b.

Reposition the patient every 1 to 2 hours.

c.

Assess for skin irritation on the patients back.

d.

Determine the patients pain level and tolerance.

ANS: B

Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

DIF: Cognitive Level: Application REF: 1619

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

31. A patient in the emergency department who is experiencing severe pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for

a.

a knee immobilizer.

b.

gentle knee flexion.

c.

activity restrictions.

d.

monitored anesthesia care (conscious sedation).

ANS: D

The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range of motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.

DIF: Cognitive Level: Application REF: 1588-1589

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

32. Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first?

a.

Elevate the leg on pillows.

b.

Apply a compression bandage.

c.

Check leg pulses and sensation.

d.

Place ice packs on the lower leg.

ANS: C

The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

DIF: Cognitive Level: Application REF: 1587 | 1598

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

33. A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to

a.

elevate the left leg.

b.

splint the lower leg.

c.

obtain information about the tetanus immunization status.

d.

check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D

The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

DIF: Cognitive Level: Application REF: 1598-1599

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is

a.

activity intolerance related to deconditioning.

b.

risk for constipation related to prolonged bed rest.

c.

risk for impaired skin integrity related to immobility.

d.

risk for infection related to disruption of skin integrity.

ANS: D

A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.

DIF: Cognitive Level: Application REF: 1594-1595

OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

35. The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first?

a.

Take the blood pressure.

b.

Assess patient orientation.

c.

Check pupil reaction to light.

d.

Assess the oxygen saturation.

ANS: D

The patients history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

DIF: Cognitive Level: Application REF: 1606

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

36. Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider?

a.

Bruising of the left thigh

b.

Complaints of left thigh pain

c.

Outward pointing toes on the left foot

d.

Prolonged capillary refill of the left foot

ANS: D

Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.

DIF: Cognitive Level: Application REF: 1607-1608

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

37. A patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient first arrives on the orthopedic unit after surgery, the nurse should

a.

place the patient in a prone position.

b.

check the surgical site for hemorrhage.

c.

remove the prosthesis and wrap the site.

d.

keep the residual leg elevated on a pillow.

ANS: B

The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.

DIF: Cognitive Level: Application REF: 1614-1615

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

38. Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take?

a.

Administer the ordered oral opioid pain medication.

b.

Instruct the patient about the benefits of ambulation.

c.

Ensure that the incisional drain has been discontinued.

d.

Change the hip dressing and document the wound appearance.

ANS: A

The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patients willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

DIF: Cognitive Level: Application REF: 1602

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

1. In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Obtain x-rays.

b. Check pedal pulses.

c. Assess lung sounds.

d. Take blood pressure.

e. Apply splint to the leg.

f. Administer tetanus prophylaxis.

ANS:

C, D, B, E, A, F

The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

DIF: Cognitive Level: Analysis REF: 1598

OBJ: Special Questions: Alternate Item Format, Prioritization

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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