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A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
- A. The leg that was assessed is free from DVT.
- B. The patient's tibial nerve is functional.
- C. Circulation to the distal extremity is adequate.
- D. The patient does not have peripheral neurovascular dysfunction.
Correct Answer: B
Rationale: Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.
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A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?
- A. Application of a walking boot
- B. Application of a cast
- C. Education on how to use crutches
- D. Passive range of motion exercises
Correct Answer: B
Rationale: After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.
A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient's plan of care. What intervention is most justified in the care of this patient?
- A. Administration of prophylactic antibiotics
- B. Total parenteral nutrition (TPN)
- C. Use of a pressure-relieving mattress
- D. Use of a Foley catheter until discharge
Correct Answer: C
Rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.
A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?
- A. Taking an opioid analgesic as ordered
- B. Applying a cold pack to the injured site
- C. Performing passive ROM exercises
- D. Applying a heating pad to the affected muscle
Correct Answer: B
Rationale: Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action?
- A. Warm the patient's foot and determine whether circulation improves.
- B. Reposition the patient with the affected foot dependent.
- C. Reassess the patient's neurovascular status in 15 minutes.
- D. Promptly inform the primary care provider.
Correct Answer: D
Rationale: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.
An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?
- A. The presence of leg shortening
- B. The patient's complaints of pain
- C. Signs of neurovascular compromise
- D. The presence of internal or external rotation
Correct Answer: C
Rationale: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.