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The nurse is caring for a patient who develops sudden shortness of breath, chest pain, and cyanosis several days after surgical fixation of a fractured femur. Which of the following actions should the nurse take first?
- A. Obtain vital signs.
- B. Notify the health care provider.
- C. Administer the prescribed anticoagulant.
- D. Apply high-flow oxygen by non-rebreather mask.
Correct Answer: D
Rationale: The patient's clinical manifestations and history are consistent with a fat embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiological need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.
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The nurse is caring for a patient who has just arrived on the orthopedic unit after a right above-the-knee amputation with an immediate prosthetic fitting. Which of the following actions should the nurse implement first?
- A. Place the patient in a prone position.
- B. Check the surgical site for hemorrhage.
- C. Remove the prosthesis and wrap the site.
- D. Keep the residual leg elevated on a pillow.
Correct Answer: B
Rationale: The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.
Before assisting a patient with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement?
- A. Administer the ordered oral opioid pain medication.
- B. Instruct the patient about the benefits of ambulation.
- C. Ensure that the incisional drain has been discontinued.
- D. Change the hip dressing and document the wound appearance.
Correct Answer: A
Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
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 providing discharge teaching to a patient with a sprained right ankle. Which of the following information should be included in the teaching plan? (Select all that apply.)
- A. Elevate the limb.
- B. Use nonsteroidal anti-inflammatory drugs as required.
- C. Apply warm moist heat for 45 minutes, three times per day.
- D. Use an elastic bandage on the ankle during activity.
- E. Use ice alternating with heat 48 hours after the injury.
Correct Answer: A,B,D
Rationale: Teaching instructions for a sprain include elevation of the limb at all times, even during sleep, using NSAIDs for discomfort, and an elastic bandage during activity. Warm moist heat can be applied but it is not to exceed 30 minutes. Ice is only to be used during the initial 24-48 hours after the injury.
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.