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The nurse is caring for a patient who is on bed rest after having a complex pelvic fracture. Which of the following assessment findings is most important to report to the health care provider?
- A. The patient states that the pelvis feels unstable.
- B. Abdominal distention is present and bowel tones are absent.
- C. There are ecchymoses on the abdomen and hips.
- D. The patient complains of pelvic pain with palpation.
Correct Answer: B
Rationale: The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.
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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.
The nurse is developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia. Which of the following nursing diagnoses is priority?
- A. Activity intolerance related to physical deconditioning
- B. Risk for constipation as evidenced by electrolyte imbalance
- C. Risk for impaired skin integrity as evidenced by pressure over bony prominence
- D. Risk for infection as evidenced by invasive procedure
Correct Answer: D
Rationale: A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.
The nurse is caring for a patient who has a comminuted fracture of the right femur and has Buck's traction in place while waiting for surgery. Which of the following actions should the nurse implement to assess for pressure areas on the patient's back and sacral area and to provide skin care?
- A. Loosen the traction and have the patient turn onto the unaffected side.
- B. Place a pillow between the patient's legs and turn gently to each side.
- C. Turn the patient partially to each side with the assistance of another nurse.
- D. Have the patient lift the buttocks by bending and pushing with the left leg.
Correct Answer: D
Rationale: The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.
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.