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The nurse is caring for a patient in the emergency department who has a soft tissue injury and an open leg fracture. Which of the following actions should the nurse implement first?
- A. If dislocation, apply compression bandage.
- B. Realignment of the bone(s).
- C. Administer tetanus with an open fracture.
- D. Apply heat to the affected area.
Correct Answer: C
Rationale: An initial action in the emergency treatment of soft tissue injuries is to administer tetanus if there is evidence of an open fracture. If dislocation is suspected, a compression bandage is contraindicated. The nurse would apply ice, not heat, to the affected area. Realignment of the bone is not to be attempted.
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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.
The nurse is caring for a patient who arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of the following prescribed collaborative interventions will the nurse implement first?
- A. Wrap the ankle and apply an ice pack.
- B. Administer naproxen 500 mg PO.
- C. Give acetaminophen with codeine.
- D. Take the patient to the radiology department for x-rays.
Correct Answer: A
Rationale: Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.
The nurse is caring for a patient in the emergency department with repetitive strain injury to the left elbow as a result of his employment as a checkout clerk in the grocery. Which of the following actions should the nurse include in the plan of care?
- A. Surgical options
- B. Elbow injections
- C. Use a wrist splint
- D. Modifications in arm movement
Correct Answer: D
Rationale: Treatment for a repetitive strain injury includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain, not elbow injuries.
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.
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.