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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.
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A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?
- A. Keep the patient's hips in abduction at all times.
- B. Keep hips flexed at no less than 90 degrees.
- C. Elevate the head of the bed to high Fowler's.
- D. Seat the patient in a low chair as soon as possible.
Correct Answer: A
Rationale: The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient's hips should be higher than the knees; as such, high seat chairs should be used.
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.
The nurse is helping to set up Buck's traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg?
- A. Within 30 minutes, then every 1 to 2 hours
- B. Within 30 minutes, then every 4 hours
- C. Within 30 minutes, then every 8 hours
- D. Within 30 minutes, then every shift
Correct Answer: A
Rationale: After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.
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.