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Before assisting a patient with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement?
- A. Administer the ordered oral opioid pain medication.
- B. Instruct the patient about the benefits of ambulation.
- C. Ensure that the incisional drain has been discontinued.
- D. Change the hip dressing and document the wound appearance.
Correct Answer: A
Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
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The nurse is caring for a patient who has a comminuted fracture of the right femur and has Buck's traction in place while waiting for surgery. Which of the following actions should the nurse implement to assess for pressure areas on the patient's back and sacral area and to provide skin care?
- A. Loosen the traction and have the patient turn onto the unaffected side.
- B. Place a pillow between the patient's legs and turn gently to each side.
- C. Turn the patient partially to each side with the assistance of another nurse.
- D. Have the patient lift the buttocks by bending and pushing with the left leg.
Correct Answer: D
Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
The nurse is caring for a patient in the emergency department who has possible left lower leg fractures. Which of the following actions should the nurse implement initially?
- A. Elevate the left leg.
- B. Splint the lower leg.
- C. Obtain information about the tetanus immunization status.
- D. Check the popliteal, dorsalis pedis, and posterior tibial pulses.
Correct Answer: D
Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.
The nurse is caring for a patient with Buck's traction who had an intracapsular fracture of the left femur. Which of the following actions should the nurse take to evaluate the effectiveness of Buck's traction?
- A. Assess for hip contractures.
- B. Monitor for hip dislocation.
- C. Check the peripheral pulses.
- D. Ask about left hip pain level.
Correct Answer: D
Rationale: Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.
The nurse is preparing a patient with lower leg fracture and an external fixation device in place for discharge. Which of the following information should the nurse include in the discharge teaching?
- A. You will need to assess and clean the pin insertion sites daily.
- B. The external fixator can be removed during the bath or shower.
- C. You will need to remain on bed rest until bone healing is complete.
- D. Prophylactic antibiotics are used until the external fixator is removed.
Correct Answer: A
Rationale: Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.
The nurse is caring for a patient who develops sudden shortness of breath, chest pain, and cyanosis several days after surgical fixation of a fractured femur. Which of the following actions should the nurse take first?
- A. Obtain vital signs.
- B. Notify the health care provider.
- C. Administer the prescribed anticoagulant.
- D. Apply high-flow oxygen by non-rebreather mask.
Correct Answer: D
Rationale: The patient's clinical manifestations and history are consistent with a fat embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiological need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.