Nokea
The nurse is caring for a patient who is 1 day postoperative below-the-knee amputation who indicates pain in the amputated limb. Which of the following actions is best for the nurse to take?
- A. Explain the reasons for the phantom limb pain.
- B. Administer prescribed analgesics to relieve the pain.
- C. Loosen the compression bandage to decrease incisional pressure.
- D. Remind the patient that this phantom pain will diminish over time.
Correct Answer: B
Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.
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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.
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 preparing a patient for discharge from the emergency department with a sprained wrist. Which of the following information should the nurse include?
- A. Keep the wrist loosely wrapped with gauze.
- B. Apply a heating pad to reduce muscle spasms.
- C. Use pillows to elevate the arm above the heart.
- D. Gently move the wrist through the range of motion.
Correct Answer: C
Rationale: Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24-48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.
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.
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.