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The nurse is caring for a client who had an amputation of the left leg above the knee. What position can the nurse place the client in several times per day to promote stump extension and prevent contractures?
- A. Supine
- B. Left lateral
- C. Prone
- D. Right lateral
Correct Answer: C
Rationale: Place the client with leg amputation in the prone position several times a day. This position promotes stump extension and prevents contractures. The other positions do neither of these things.
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The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
- A. Scrubbing the drainage from around the pin site
- B. Obtaining a culture
- C. Applying iodine-based solution
- D. Apply ointment to the pin site.
Correct Answer: B
Rationale: A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
A client is having traction applied to a fractured left lower extremity prior to surgery. What outcome(s) does the nurse expect from the application of the traction for the client? Select all that apply.
- A. Surgery will not be required.
- B. Muscle spasms will be relieved.
- C. The bones of the left leg will be aligned.
- D. Immobilization of the left leg will be maintained.
- E. Less pain medication will be required.
Correct Answer: B,C,D
Rationale: Traction is used to relieve muscle spasm, align bones, and maintain immobilization when used properly. It will not replace surgery to correct the fracture. The client will still require pain medication prior to surgical correction.
The nurse is caring for a client who has had a fracture reduction using a cast. What would be most important for the nurse to assess?
- A. Cardiac and respiratory status
- B. Renal and hepatic function
- C. Sleep status
- D. Sensation and mobility status
Correct Answer: D
Rationale: After cast application, the nurse should assess circulation, sensation, and mobility in exposed fingers and toes every 1 to 2 hours. Assessment of cardiac, respiratory, hepatic, and renal status would be priorities if the client experienced multiple fractures or had an open reduction. The client's sleep status would be a low priority.
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite what as an advantage of a plaster cast?
- A. Better molding to the client
- B. Quicker drying
- C. Longer lasting
- D. More breathable
Correct Answer: A
Rationale: Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
- A. Blood pressure of 140/90 mm Hg
- B. Crackles in the lung bases
- C. SUBJECT: Client complains of pain in the affected rib area when taking a deep breath
- D. Heart rate of 94 beats/minute
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.