Exam View - Chapter 47 - Ignatavicius: Medical-Surgical Nursing, 10th Edition Bank PDF

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Ignatavicius: Medical-Surgical Nursing, 10th Edition
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Chapter 47: Concepts of Care for Patients With Musculoskeletal Trauma Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased r

nurse’s first action? a. Place the client in a high-Fowler position. b. Document the client’s oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider. ANS: A

The client is experiencing respiratory distress which could be due to pulmonary embolus, fat embolism s Regardless of the cause, the nurse would place the client in a sitting position first and then perform addit would likely be needed, especially if the client’s oxygen saturation was under 95%. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Complications MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning

affected foot. For which potential complication would the nurse anticipate? a. Delayed bone healing b. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome ANS: B

Burning pain and tingling that occurs weeks or months after a fracture or other trauma may indicate com syndrome. Compartment syndrome tends to occur within days of the initial injury. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. An older client who fell at home is admitted to the emergency department and reports pain in her left gro

knee. What action would the nurse anticipate? a. Administer IV push morphine. b. Prepare for application of a leg cast. c. Begin oxygen at 6 L/min via mask. d. Obtain a left hip x-ray. ANS: D

The location of the client’s pain indicates a possible fractured hip and therefore an x-ray of the hip is nee appropriate and oxygen may not be needed. Medication to make the client more comfortable would likel diagnosis is determined. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. H

the nurse expect for a capillary refill in it is within normal range? a. 20 seconds b. 15 seconds c. 10 seconds d. 5 seconds ANS: D

The normal capillary refill is usually 3 seconds, but for older adults, the refill usually takes up to 5 secon associated with aging.

DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the

deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis ANS: D

Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures ar extremities and the client has additional risk factors for thrombus formation. Other risk factors include o contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clie risk factors for DVT. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which stateme

as part of the teaching about this client’s care? a. “Remove the traction when re-positioning the client.” b. “Assess the client’s skin when performing a bed bath.” c. “Provide pin care by using alcohol wipes to clean the sites.” d. “Ensure that the weights remain freely hanging at all times.” ANS: D

Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to should remain in traction during hygiene activities. The nurse would assess the client’s skin and provide patient who is in traction; this would not be delegated to the AP. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fracture, Traction MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle

priority action? a. Keep the client warm and comfortable. b. Assess airway, breathing, and circulation. c. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint. ANS: B

As part of the primary survey, the nurse would ensure that the client does not have any life-threatening p ABCs first. If there are not major problems, then the nurse could attend to the injured extremity. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of d

action is the most important ? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze. ANS: C

The primary health care provider should be notified to examine the client and determine the source of th assessment should be documented, but that is not the most important action. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in t

How would the nurse respond? a. “The pain you are feeling does not actually exist.” b. “This type of pain is common and will eventually go away.” “Would you like to learn how to use imagery to minimize your pain?”

11. A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, “The cast is loose en

would the nurse respond? a. “Keep your arm above the level of your heart.” b. “As your muscles atrophy, the cast is expected to loosen.” c. “I will wrap a bandage around the cast to prevent it from slipping.” d. “You need a new cast now that the swelling is decreased.” ANS: D

Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After t the cast is loose enough to permit two or more fingers between the cast and the client’s skin, the cast nee Elevating the arm will not solve the problem, and the client’s muscles should not atrophy while in a cast elastic bandage will not prevent slippage of the cast. DIF: TOP: KEY: MSC:

Understanding Integrated Process: Nursing Process: Planning and Implementation Fracture, Casts Client Needs Category: Physiological Integrity: Physiological Adaptation

12. A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a a. Hypertension b. Diarrhea c. Infection d. Hematuria ANS: D

The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage tha the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic sh hypotension and tachycardia. Diarrhea and infection are not common complications of a pelvic fracture. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 13. A nurse cares for a client placed in skeletal traction. The client asks, “What is the primary purpose of thi

would the nurse respond? a. “Skeletal traction will assist in realigning your fractured bone.” b. “This treatment will prevent future complications and back pain.” c. “Traction decreases muscle spasms that occur with a fracture.” d. “This type of traction minimizes damage as a result of fracture treatment.” ANS: A

Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last r to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are n skeletal traction. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Fracture, Traction MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 14. The nurse is caring for a postoperative client who have a regional nerve blockade for a surgical tibial fra

What assessment finding would the nurse expect? a. Client reports nausea and vomiting. b. Client reports tingling in the surgical leg. c. Client responds well to imagery. d. Client reports little to no pain. ANS: D

A regional nerve blockade can last for about 24 hours so the client has little to no pain until it wears off. and therefore does not cause nausea or vomiting. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Perioperative care MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

15. A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client r

foot. Which prescribed medication would the nurse most likely administer? a. Intravenous morphine b Oral acetaminophen

16. A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Whic

nurse include in this client’s plan of care? a. Place pillows between the client’s knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position. ANS: B

Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of am infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-po frequently, and therefore should not be restricted to bedrest. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Amputation, Perioperative care MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 17. The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair. What health

include? a. “Place the cane on your left side.” b. “Move the cane and your left leg at the same time.” c. “Be sure the cane is parallel to your waist.” d. “Use the cane only when your right leg is painful.” ANS: A

The cane should be placed on the unaffected side (left for this client) and moved forward with the injure to provide support. The cane should be parallel to the stylus of the wrist and used at all times when ambu DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Fracture, Rehabilitation MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 18. A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the n a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing. ANS: A

A client’s medical alert bracelet or any other jewelry would be removed from the fractured arm before th swells. Immobilization, positioning, and dressing should occur after the bracelet is removed. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Fracture, Management MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 19. A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed ANS: B

The client with numbness and/or tingling of the extremity may be displaying the first signs of acute com an acute problem that requires immediate intervention because of possible decreased circulation. Modera expected assessment after a fracture. These findings can be treated with comfort measures. Being cold c additional blankets or by increasing the temperature of the room. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fracture, Complications MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 20. After teaching a client with a fractured humerus, the nurse assesses the client’s understanding. Which di

that the client correctly understands the nutrition needed to assist in healing the fracture?...