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A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery. Which actions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Elevate heels off the bed with a pillow.
- B. Ambulate the client on the first postoperative day.
- C. Use an abduction pillow to prevent hip subluxation.
- D. Re-position the client every 2 hours.
- E. Push the client's patient-controlled analgesia button.
Correct Answer: A,B,C,D
Rationale: Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown, ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should never push the patient-controlled analgesia button for the client.
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A nurse cares for a client who had a long-leg cast applied last week. The client states, 'I cannot seem to catch my breath and I feel a bit light-headed.' Which action should the nurse take next?
- A. Auscultate the client's lung fields anteriorly and posteriorly.
- B. Administer oxygen via nasal cannula.
- C. Check the client's oxygen saturation.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Shortness of breath and light-headedness in a client with a long-leg cast may indicate a pulmonary embolism, a serious complication possibly related to fat embolism syndrome from the fracture. Notifying the healthcare provider immediately is the priority to ensure rapid evaluation and treatment. Auscultation, oxygen administration, and checking oxygen saturation are secondary actions that may follow after the provider is notified.
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 cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?
- A. This traction will prevent fat aligning your fractured bone.
- B. This traction will prevent future complications and back pain.
- C. Traction decreases muscle spasms that occur with a fracture.
- D. This type of traction minimizes damage as a result of fracture treatment.
Correct Answer: A
Rationale: Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a secondary benefit, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage, but these are not the primary purposes of skeletal traction.
A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?
- A. Meperidine (Demerol) 30 mg IV every 4 hours.
- B. Patient-controlled analgesia (PCA) with morphine sulfate.
- C. Percocet 2 tablets orally every 6 hours PRN for pain.
- D. Percocet 2 tablets every 6 hours for pain.
Correct Answer: A
Rationale: Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this client's pain management.
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.