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A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?
- A. Taking an opioid analgesic as ordered
- B. Applying a cold pack to the injured site
- C. Performing passive ROM exercises
- D. Applying a heating pad to the affected muscle
Correct Answer: B
Rationale: Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.
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A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient's plan of care. What intervention is most justified in the care of this patient?
- A. Administration of prophylactic antibiotics
- B. Total parenteral nutrition (TPN)
- C. Use of a pressure-relieving mattress
- D. Use of a Foley catheter until discharge
Correct Answer: C
Rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.
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.
A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions?
- A. Improving the patient's level of function
- B. Helping the patient come to terms with limitations
- C. Administering medications safely
- D. Improving the patient's adherence to treatment
Correct Answer: A
Rationale: Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional 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 planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
- A. Risk for Impaired Skin Integrity
- B. Risk for Falls
- C. Risk for Imbalanced Fluid Volume
- D. Risk for Aspiration
Correct Answer: A
Rationale: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.