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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.
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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.
The nurse is caring for a patient with a fractured pelvis and on day 2 of the hospitalization the patient develops acute onset confusion. Which of the following actions should the nurse take first?
- A. Take the blood pressure.
- B. Assess patient orientation.
- C. Check pupil reaction to light.
- D. Assess the oxygen saturation.
Correct Answer: D
Rationale: The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.
The nurse is counseling a patient about ways to prevent fractures. Which of the following information should the nurse include?
- A. Tack down throw rugs in the home.
- B. Most falls happen outside the home.
- C. Buy shoes that provide good support and are comfortable.
- D. Activities of daily living provide range of motion.
Correct Answer: C
Rationale: Comfortable shoes with good support will help decrease the risk for falls. Throw rugs should be eliminated, not just tacked down. Most falls occur inside the home, and activities of daily living do not necessarily provide sufficient range of motion to prevent fractures.
After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, 'If they want to cut off my foot, they should just shoot me instead.' Which of the following responses by the nurse is best?
- A. Many people are able to function normally with a foot prosthesis.
- B. I understand that you are upset, but you may lose the foot anyway.
- C. Tell me what you know about what your options for treatment are.
- D. If you do not want the surgery, you do not have to have an amputation.
Correct Answer: C
Rationale: The initial nursing action should be to assess the patient's knowledge level and feelings about the options available. Discussion about the patient's option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.
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.