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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.
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A nurse is caring for a patient receiving skeletal traction. Due to the patient's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?
- A. Perform chest physiotherapy once per shift and as needed.
- B. Teach the patient to perform deep breathing and coughing exercises.
- C. Administer prophylactic antibiotics as ordered.
- D. Administer nebulized bronchodilators and corticosteroids as ordered.
Correct Answer: B
Rationale: To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.
The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
- A. Increased warmth of the calf
- B. Decreased circumference of the calf
- C. Loss of sensation to the calf
- D. Pale-appearing calf
Correct Answer: A
Rationale: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.
A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication?
- A. Cellulitis
- B. Septic arthritis
- C. Sepsis
- D. Osteomyelitis
Correct Answer: D
Rationale: Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the risk of osteomyelitis. Orthopedic patients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical patients.
A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action?
- A. Administer pain medication as ordered.
- B. Assess the surgical site and the affected extremity.
- C. Reassure the patient that pain is a direct result of increased activity.
- D. Assess the patient for signs and symptoms of systemic infection.
Correct Answer: B
Rationale: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.
A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?
- A. Application of a walking boot
- B. Application of a cast
- C. Education on how to use crutches
- D. Passive range of motion exercises
Correct Answer: B
Rationale: After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.