Nokea
A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patient's cast care?
- A. Cover the cast with a blanket until the cast dries.
- B. Keep your right leg elevated above heart level.
- C. Use a clean object to scratch itches inside the cast.
- D. A foul smell from the cast is normal after the first few days.
Correct Answer: B
Rationale: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.
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The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
- A. Encourage independence with ADLs whenever possible.
- B. Monitor the patient's nutritional status closely.
- C. Teach the patient to perform ankle and foot exercises within the limitations of traction.
- D. Administer clopidogrel (Plavix) as ordered.
Correct Answer: C
Rationale: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.
A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
- A. Shifting one's weight in bed
- B. Bearing down while having a bowel movement
- C. Turning from side to side
- D. Coughing without splinting
Correct Answer: C
Rationale: To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.
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.
A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply.
- A. Preventing additional injury
- B. Immobilizing prior to surgery
- C. Providing support
- D. Controlling movement
- E. Promoting bone remodeling
Correct Answer: A,C,D
Rationale: Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.
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.