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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.
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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.
A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?
- A. Using crutches efficiently
- B. Exercising joints above and below the cast, as ordered
- C. Removing the cast correctly at the end of the treatment period
- D. Reporting signs of impaired circulation
Correct Answer: D
Rationale: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.
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 patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action?
- A. Administer pain medication as ordered.
- B. Assess the surgical site and the affected extremity.
- C. Reassure the patient that pain is a direct result of increased activity.
- D. Assess the patient for signs and symptoms of systemic infection.
Correct Answer: B
Rationale: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.
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.