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An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?
- A. The presence of leg shortening
- B. The patient's complaints of pain
- C. Signs of neurovascular compromise
- D. The presence of internal or external rotation
Correct Answer: C
Rationale: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.
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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 nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?
- A. Using crutches efficiently
- B. Exercising joints above and below the cast, as ordered
- C. Removing the cast correctly at the end of the treatment period
- D. Reporting signs of impaired circulation
Correct Answer: D
Rationale: Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.
A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
- A. The leg that was assessed is free from DVT.
- B. The patient's tibial nerve is functional.
- C. Circulation to the distal extremity is adequate.
- D. The patient does not have peripheral neurovascular dysfunction.
Correct Answer: B
Rationale: Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.
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.
A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have a peroneal nerve injury?
- A. Numbness and burning of the foot
- B. Pallor to the dorsal surface of the foot
- C. Visible cyanosis in the toes
- D. Inadequate capillary refill to the toes
Correct Answer: A
Rationale: Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.