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A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurses most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient?
- A. Electrolyte assessment
- B. Electrocardiogram
- C. Arterial blood gases
- D. Abdominal ultrasound
Correct Answer: C
Rationale: Subtle personality changes, restlessness, irritability, or confusion in a patient who has sustained a fracture are indications for immediate arterial blood gas studies due to the possibility of fat embolism syndrome. This assessment finding does not indicate an immediate need for electrolyte levels, an ECG, or abdominal ultrasound.
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A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?
- A. Encouraging the patient to turn from side to side and to assume a prone position
- B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation
- C. Minimizing movement of the flexor muscles of the hip
- D. Encouraging the patient to sit in a chair for at least 8 hours a day
Correct Answer: A
Rationale: The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.
A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patients need for exercise?
- A. Performing gentle leg lifts with both legs
- B. Performing massage to stimulate circulation
- C. Encouraging frequent use of the overbed trapeze
- D. Encouraging the patient to log roll side to side once per hour
Correct Answer: C
Rationale: The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation. Independent logrolling may result in injury due to the location of the fracture. Leg lifts would be contraindicated for the same reason. Massage by the nurse is not a substitute for exercise.
A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture?
- A. Avoid requesting analgesia unless pain becomes unbearable.
- B. Use supplementary oxygen when transferring or mobilizing.
- C. Increase fluid intake and perform prescribed foot exercises.
- D. Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?
- A. Apply heat for the first 24 to 48 hours after the injury.
- B. Maintain the ankle in a dependent position.
- C. Exercise hourly by performing rotation exercises of the ankle.
- D. Keep an elastic compression bandage on the ankle.
Correct Answer: D
Rationale: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action?
- A. Inform the surgeon of this finding.
- B. Explain the risks of flexion contracture to the patient.
- C. Transfer the patient to a sitting position.
- D. Encourage the patient to perform active ROM exercises with the residual limb.
Correct Answer: B
Rationale: The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the patients surgeon. Encouraging exercise or transferring the patient does not address the risk of flexion contracture.