Nokea
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.
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A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient?
- A. The cast will feel cool to touch for the first 30 minutes.
- B. The cast should be wrapped snuggly with a towel until the patient gets home.
- C. The cast should be supported on a board while drying.
- D. The cast will only have full strength when dry.
Correct Answer: D
Rationale: A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped.
While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
- A. Risk for Infection
- B. Risk for Peripheral Neurovascular Dysfunction
- C. Unilateral Neglect
- D. Disturbed Kinesthetic Sensory Perception
Correct Answer: B
Rationale: The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction. There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.
A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient's affected limb are spastic. How does this change in muscle tone affect the patient's traction prescription?
- A. Traction must temporarily be aligned in a slightly different direction.
- B. Extra weight is needed initially to keep the limb in proper alignment.
- C. A lighter weight should be initially used.
- D. Weight will temporarily alternate between heavier and lighter weights.
Correct Answer: B
Rationale: The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.
A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
- A. Use of a cardiopulmonary bypass machine
- B. Postoperative blood salvage
- C. Prophylactic blood transfusion
- D. Autologous blood donation
Correct Answer: D
Rationale: Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.
A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?
- A. Place slight additional tension on the traction cords.
- B. Release the weights and replace them immediately after positioning.
- C. Reposition the bed instead of repositioning the patient.
- D. Maintain consistent traction tension while repositioning.
Correct Answer: D
Rationale: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the patient is not feasible.