Nokea
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.
You may also like to solve these questions
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.
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.
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.
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.
The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
- A. Encourage independence with ADLs whenever possible.
- B. Monitor the patient's nutritional status closely.
- C. Teach the patient to perform ankle and foot exercises within the limitations of traction.
- D. Administer clopidogrel (Plavix) as ordered.
Correct Answer: C
Rationale: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.