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The nurse is caring for a patient in the emergency department following a motor vehicle accident who has massive right lower leg swelling. Which of the following actions will the nurse take first?
- A. Elevate the leg on pillows.
- B. Apply a compression bandage.
- C. Check leg pulses and sensation.
- D. Place ice packs on the lower leg.
Correct Answer: C
Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.
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The nurse is providing discharge teaching to a patient who has a short-arm plaster cast applied. Which of the following patient statements indicate a good understanding of the discharge teaching?
- A. I can get the cast wet as long as I dry it right away with a hair dryer.
- B. I should avoid moving my fingers and elbow until the cast is removed.
- C. I will apply an ice pack to the cast over the fracture site for the next 24 hours.
- D. I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.
Correct Answer: C
Rationale: Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.
The nurse is preparing a patient for discharge 4 days after insertion of a femoral head prosthesis using a posterior approach. Which of the following patient statements indicate a need for additional discharge instructions?
- A. I should not cross my legs while sitting.
- B. I will use a toilet elevator on the toilet seat.
- C. I will have someone else put on my shoes and socks.
- D. I can sleep in any position that is comfortable for me.
Correct Answer: D
Rationale: The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.
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 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 preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which of the following actions should the nurse take first?
- A. Use a mechanical lift to transfer the patient from the bed to the chair.
- B. Check the postoperative orders for the patient's weight-bearing status.
- C. Avoid administration of pain medications before getting the patient up.
- D. Delegate the transfer of the patient out of bed to an unregulated care provider (UCP).
Correct Answer: B
Rationale: The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.