Nokea
The nurse is caring for a patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Assess the incision for redness.
- C. Reposition the left leg on pillows.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
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The nurse is providing home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm. Which of the following information should the nurse include in the teaching plan?
- A. Keep the hand immobile to prevent soft tissue swelling.
- B. Keep the right shoulder elevated on a pillow or cushion.
- C. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury.
- D. Call the health care provider for increased swelling or numbness.
Correct Answer: D
Rationale: Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and vessels. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder. The forearm should be elevated to reduce swelling. NSAIDs can be used to manage pain and swelling.
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 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 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.
Which of the following information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider?
- A. Bruising of the left thigh
- B. Complaints of left thigh pain
- C. Outward pointing toes on the left foot
- D. Prolonged capillary refill of the left foot
Correct Answer: D
Rationale: Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.