Nokea
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.
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A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching?
- A. I'll need to keep several pillows between my legs at night.
- B. I need to remember not to cross my legs. It's such a habit.
- C. The occupational therapist is showing me how to use a sock puller to help me get dressed.
- D. I will need my husband to assist me in getting off the low toilet seat at home.
Correct Answer: D
Rationale: To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.
A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?
- A. Russell's traction
- B. Dunlop's traction
- C. Buck's extension traction
- D. Cervical head halter
Correct Answer: C
Rationale: Buck's extension is used for fractures of the proximal femur. Russell's traction is used for lower leg fractures. Dunlop's traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.
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 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 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.