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A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The findings by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small $1 \mathrm{~cm}$ area of blood on cast. Which action will the nurse take?
- A. Notify charge nurse of impending compartment syndrome.
- B. Document that all findings are within normal limits.
- C. Inform charge nurse about probable hemorrhage.
- D. Place warm compresses on left foot.
Correct Answer: B
Rationale: All of the findings are within normal limits. A small amount of blood on the cast is expected and should be monitored. There is no evidence of impending compartment syndrome or hemorrhage. Warm compresses are not necessary, and could cause swelling to develop.
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Which is a vital function muscles perform when they contract?
- A. Absorb uric acid
- B. Maintenance of posture
- C. Motion
- D. Store minerals
- E. Production of heat
- F. To assist in return of venous blood to the left side of the heart
Correct Answer: B,C,E
Rationale: The vital functions muscles perform when they contract are maintenance of posture, motion, and production of $85 \%$ of body heat. Muscles do not absorb uric acid, store minerals. Venous blood is returned to the right side of the heart.
Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse notes the patient has a pulse of 110, respirations at 25, labored respirations and crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of which disorder?
- A. impending pneumonia.
- B. atelectasis.
- C. fat embolism.
- D. anxiety attack.
Correct Answer: C
Rationale: A pulmonary fat embolism involves the embolization of fat tissue with platelets and circulation of free fatty acids within the pulmonary circulation. Dyspnea, tachypnea, and chest pain are symptomatic of a fat embolus. These signs are not associated with impending pneumonia or atelectasis. The patient is undergoing a major complication; this is not an anxiety attack.
When reinforcing teaching the patient about osteoarthritis, the nurse should include which characteristic about osteoarthritis?
- A. will cause the formation of Heberden nodes.
- B. can involve other organs.
- C. results from wear and tear.
- D. may affect only one side of the body.
- E. may cause constitutional symptoms of fatigue and fever.
- F. will cause marked erythema and edema of hands.
Correct Answer: A,C,D
Rationale: Osteoarthritis is a disease caused by wear and tear of the joints, causing the appearance of Heberden nodes on the fingers without marked edema or erythema. The disease may only affect one side of the body. Osteoarthritis does not involve other organs and does not cause constitutional symptoms. Marked erythema and hand edema are not associated with osteoarthritis.
Which will the home health nurse include monitoring for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis?
- A. Urinary output
- B. Respiratory effort
- C. Sleep cycle
- D. Nutritional status
Correct Answer: B
Rationale: Severe kyphosis may hinder the patient's ability to expand the rib cage and interfere with easy respiration. Severe kyphosis due to ankylosis will not affect the urinary output or the sleep cycle. Nutritional status is not necessarily impaired from severe kyphosis.
The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. Which is the appropriate nursing response?
- A. You have calcium oxalate deposits that are seen in gouty arthritis.'
- B. The inflammation is from small accumulations of uric acid crystals, which are called tophi.'
- C. The small nodules are not related to the arthritis condition.'
- D. You have fat deposits that are common with gouty arthritis.'
Correct Answer: B
Rationale: Gout is a metabolic disease resulting from an accumulation of uric acid in the blood. It is an acute inflammatory condition associated with ineffective metabolism of purines. Although some patients with gout also have kidney stones, and some kidney stones are caused by calcium oxalate deposits, gout is not caused from calcium oxalate deposits. A patient with gout usually has excruciating pain, edema and inflammation in the affected joint, not small nodules. Fat deposits are not associated with gouty arthritis.