Nokea
The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?
- A. Keep the affected leg in a position of adduction.
- B. Have the patient reposition himself independently.
- C. Protect the affected leg from internal rotation.
- D. Keep the hip flexed by placing pillows under the patient's knee.
Correct Answer: C
Rationale: Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. The patient may not be capable of safe independent repositioning at this early stage of recovery.
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A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?
- A. Obstructed arterial blood flow to the forearm and hand
- B. Simultaneous pressure on the ulnar and radial nerves
- C. Irritation of Merkel cells in the patient's skin surfaces
- D. Uncontrolled muscle spasms in the patient's forearm
Correct Answer: A
Rationale: Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.
The nurse is helping to set up Buck's traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg?
- A. Within 30 minutes, then every 1 to 2 hours
- B. Within 30 minutes, then every 4 hours
- C. Within 30 minutes, then every 8 hours
- D. Within 30 minutes, then every shift
Correct Answer: A
Rationale: After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.
A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions?
- A. Improving the patient's level of function
- B. Helping the patient come to terms with limitations
- C. Administering medications safely
- D. Improving the patient's adherence to treatment
Correct Answer: A
Rationale: Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.
A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
- A. The leg that was assessed is free from DVT.
- B. The patient's tibial nerve is functional.
- C. Circulation to the distal extremity is adequate.
- D. The patient does not have peripheral neurovascular dysfunction.
Correct Answer: B
Rationale: Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.
A patient is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
- A. Risk for Impaired Skin Integrity
- B. Risk for Falls
- C. Risk for Imbalanced Fluid Volume
- D. Risk for Aspiration
Correct Answer: A
Rationale: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.