Nokea
A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
- A. Shifting one's weight in bed
- B. Bearing down while having a bowel movement
- C. Turning from side to side
- D. Coughing without splinting
Correct Answer: C
Rationale: To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.
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A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
- A. Use of a cardiopulmonary bypass machine
- B. Postoperative blood salvage
- C. Prophylactic blood transfusion
- D. Autologous blood donation
Correct Answer: D
Rationale: Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?
- A. Subcutaneous emphysema
- B. Skin breakdown
- C. Compartment syndrome
- D. Disuse syndrome
Correct Answer: C
Rationale: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.
A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?
- A. Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious.
- B. Give the patient a sterile tongue depressor to use for scratching instead of the pencil.
- C. Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.
- D. Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.
Correct Answer: C
Rationale: Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.
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 is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
- A. Risk for Impaired Skin Integrity
- B. Risk for Falls
- C. Risk for Imbalanced Fluid Volume
- D. Risk for Aspiration
Correct Answer: A
Rationale: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.