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A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care?
- A. Apply occlusive dressings to the pin sites.
- B. Encourage the patient to push up with the elbows when repositioning.
- C. Encourage the patient to perform isometric exercises once a shift.
- D. Assess the pin insertion site every 8 hours.
Correct Answer: D
Rationale: The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.
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A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?
- A. Patient is able to perform ADLs independently.
- B. Patient is able to perform transfers safely.
- C. Patient is able to weight-bear equally on both legs.
- D. Patient is able to demonstrate full ROM of the affected hip.
Correct Answer: B
Rationale: The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement.
A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
- A. Make sure you don't bring your knees close together.
- B. Try to lie as still as possible for the first few days.
- C. Try to avoid bending your knees until next week.
- D. Keep your legs higher than your chest whenever you can.
Correct Answer: A
Rationale: After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patient's legs do not need to be higher than the level of the chest.
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
- A. Knots in the rope should not be resting against pulleys.
- B. Weights should rest against the bed rails.
- C. The end of the limb in traction should be braced by the footboard of the bed.
- D. Skeletal traction may be removed for brief periods to facilitate the patient's independence.
Correct Answer: A
Rationale: Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.
A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?
- A. Russell's traction
- B. Dunlop's traction
- C. Buck's extension traction
- D. Cervical head halter
Correct Answer: C
Rationale: Buck's extension is used for fractures of the proximal femur. Russell's traction is used for lower leg fractures. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.
While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
- A. Risk for Infection
- B. Risk for Peripheral Neurovascular Dysfunction
- C. Unilateral Neglect
- D. Disturbed Kinesthetic Sensory Perception
Correct Answer: B
Rationale: The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction. There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.