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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.
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The nurse is admitting a patient to the emergency department after falling on the right arm and shoulder. Which of the following findings is most important for the nurse to communicate to the health care provider immediately?
- A. There is bruising at the shoulder area.
- B. The right arm appears shorter than the left.
- C. There is decreased range of motion of the shoulder.
- D. The patient is complaining of arm and shoulder pain.
Correct Answer: B
Rationale: A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.
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 with a long-arm cast on the left arm. Which of the following nursing actions should be included in the plan of care?
- A. Suspend the arm from an IV pole.
- B. Immobilize the fingers on the left hand with gauze dressings.
- C. Assess the left axilla and change absorbent dressings as needed.
- D. Assist the patient in passive range of motion for the left arm.
Correct Answer: C
Rationale: The axilla can become excoriated when a long-arm cast is in place, and the nurse should check the axilla and apply absorbent dressings as needed to prevent skin breakdown. The arm should not be suspended from an IV pole, as this could cause discomfort and misalignment. The fingers should be encouraged to move to prevent stiffness. Passive range of motion is not typically needed unless specified, as the patient can actively move unaffected joints.
The nurse is caring for a patient with a left femur fracture who has a hip spica cast applied. Which of the following nursing interventions should be included in the plan of care?
- A. Avoid placing the patient in the prone position.
- B. Use the cast support bar to reposition the patient.
- C. Ask the patient about any abdominal discomfort or nausea.
- D. Discuss the reasons for remaining on bed rest for several weeks.
Correct Answer: C
Rationale: Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.
The nurse is planning discharge teaching for a patient who has had a repair of a fractured mandible. Which of the following information will the nurse include in the teaching plan?
- A. When and how to cut the immobilizing wires
- B. Self-administration of nasogastric tube feedings
- C. The use of sterile technique for dressing changes
- D. The importance of including high-fibre foods in the diet
Correct Answer: A
Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fibre foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.