Nokea
In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident?
- A. Obtain x-rays.
- B. Check pedal pulses.
- C. Assess lung sounds.
- D. Take blood pressure.
- E. Apply splint to the leg.
- F. Administer tetanus prophylaxis.
Correct Answer: C,D,B,E,A,F
Rationale: The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.
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The nurse is caring for a patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Assess the incision for redness.
- C. Reposition the left leg on pillows.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
The nurse is preparing a patient who had an above-the-knee amputation for discharge. Which of the following patient statements indicates that the nurse's discharge teaching has been effective?
- A. I should lie on my abdomen for 30 minutes three or four times a day.
- B. I should elevate my residual limb on a pillow two or three times a day.
- C. I should change the limb sock when it becomes soiled or stretched out.
- D. I should use lotion on the stump to prevent drying and cracking of the skin.
Correct Answer: A
Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.
The nurse is caring for a patient in the emergency department who is experiencing severe pain and is diagnosed with a patellar dislocation. Which of the following actions should the nurse implement first?
- A. Applying a knee immobilizer
- B. Implementing passive knee flexion
- C. Limiting activity restrictions
- D. Preparing the patient for conscious sedation
Correct Answer: D
Rationale: The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or conscious sedation. Immobilization, gentle range of motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.
The nurse is caring for a patient who is 1 day postoperative below-the-knee amputation who indicates pain in the amputated limb. Which of the following actions is best for the nurse to take?
- A. Explain the reasons for the phantom limb pain.
- B. Administer prescribed analgesics to relieve the pain.
- C. Loosen the compression bandage to decrease incisional pressure.
- D. Remind the patient that this phantom pain will diminish over time.
Correct Answer: B
Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.
Which of the following nursing actions should the nurse include in the plan of care for a patient who has had a total knee arthroplasty?
- A. Avoid extension of the knee beyond 120 degrees.
- B. Use a compression bandage to keep the knee flexed.
- C. Start progressive knee exercises to obtain 90-degree flexion.
- D. Teach about the need to avoid weight bearing for 4 weeks.
Correct Answer: C
Rationale: After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.