Nokea
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?
- A. Ineffective Thermoregulation
- B. Risk-Prone Health Behavior
- C. Disturbed Body Image
- D. Deficient Diversion Activity
Correct Answer: C
Rationale: Amputations present a serious threat to any patients body image. None of the other listed diagnoses is specifically associated with amputation.
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The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the-knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside?
- A. A tourniquet
- B. A syringe preloaded with vitamin K
- C. A unit of packed red blood cells, placed on ice
- D. A dose of protamine sulfate
Correct Answer: A
Rationale: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patients bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding.
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms?
- A. Subluxated right hip
- B. Right hip contusion
- C. Hip strain
- D. Traumatic hip dislocation
Correct Answer: D
Rationale: Signs and symptoms of a traumatic dislocation include acute pain, change in positioning of the joint, shortening of the extremity, deformity, and decreased mobility. A subluxation would cause moderate deformity, or possibly no deformity. A contusion or strain would not cause obvious deformities.
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply.
- A. Systemic infection
- B. Complex regional pain syndrome
- C. Deep vein thrombosis
- D. Compartment syndrome
- E. Fat embolism
Correct Answer: C,D,E
Rationale: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and CRPS are later complications of fractures.
A patient with a simple arm is receiving discharge education from the nurse. What would the nurse instruct the patient to do?
- A. Elevate the affected extremity to shoulder level when at rest.
- B. Engage in exercises that strengthen the unaffected muscles.
- C. Apply topical anesthetics to accessible skin surfaces as needed.
- D. Avoid using analgesics so that further damage is not masked.
Correct Answer: B
Rationale: The nurse will encourage the patient to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?
- A. Prepare the patient for opening or bivalving of the cast.
- B. Obtain an order for a different analgesic.
- C. Encourage the patient to wiggle and move the fingers.
- D. Petal the edges of the patients cast.
Correct Answer: A
Rationale: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.