Nokea
A nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?
- A. Straining during a bowel movement
- B. Bending down to put on socks
- C. Lifting items above shoulder level
- D. Transferring from a sitting to standing position
Correct Answer: B
Rationale: Bending to put on socks or shoes can cause hip dislocation. None of the other listed actions poses a serious threat to the integrity of the new hip.
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A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?
- A. Obstructed arterial blood flow to the forearm and hand
- B. Simultaneous pressure on the ulnar and radial nerves
- C. Irritation of Merkel cells in the patient's skin surfaces
- D. Uncontrolled muscle spasms in the patient's forearm
Correct Answer: A
Rationale: Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.
A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding?
- A. Inform the primary care provider promptly.
- B. Document this as an expected assessment finding.
- C. Limit the patient's fluid intake to 2 liters for the next 24 hours.
- D. Administer a loop diuretic as ordered.
Correct Answer: B
Rationale: Drainage of 200 to 500 mL in the first 24 hours is expected. Consequently, the nurse does not need to inform the physician. Fluid restriction and medication administration are not indicated.
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.
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 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.