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A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
- A. Immobilize the client's arm.
- B. Assess the client's distal pulse.
- C. Monitor for signs of infection.
- D. Administer prescribed steroids.
Correct Answer: A
Rationale: A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
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A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?
- A. The pain you are feeling does not actually exist.
- B. This type of pain will not actually go away.
- C. Would you like to learn how to use imagery to minimize your pain?
- D. How would you describe the pain that you are feeling?
Correct Answer: D
Rationale: The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating it does not exist or will not go away. Offering imagery techniques may be appropriate after assessing the pain.
A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- A. Stability to maintain abduction of the affected arm for more than 90 seconds.
- B. Shoulder pain that is relieved with overhead stretches and at night.
- C. Inability to initiate or maintain abduction of the affected arm at the shoulder.
- D. Referred pain to the shoulder and arm opposite the affected shoulder.
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.
A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?
- A. Pain of 4 on a scale of 0 to 10.
- B. Numbness in the extremity.
- C. Swollen extremity at the injury site.
- D. Feeling cold while lying in bed.
Correct Answer: B
Rationale: The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling are expected after a fracture and can be treated with comfort measures. Feeling cold can be addressed with additional blankets or increasing the room temperature.
An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor? (Select all that apply.)
- A. Temperature
- B. Urinary output
- C. Blood pressure
- D. Pulse rate
- E. Level of consciousness
Correct Answer: A,B,C,D,E
Rationale: A client with a pelvic fracture is at risk for complications such as internal bleeding, infection, and shock. Monitoring temperature can indicate infection, urinary output can reflect kidney function or hypovolemia, blood pressure and pulse rate can indicate hemodynamic stability, and level of consciousness can signal neurological changes or shock. These assessments are critical for client safety.
A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation should the nurse share with the client? (Select all that apply.)
- A. It leads to minimal blood loss.
- B. It allows for early ambulation.
- C. It promotes healing.
- D. It increases blood supply to tissues.
- E. It stabilizes the fracture site.
Correct Answer: A,B,C,E
Rationale: External fixation is a system in which pins or wires are inserted through the skin and bone, connected to an external frame. It leads to minimal blood loss, allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. It does not increase blood supply to the tissues.