Nokea
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.
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The nurse is caring for a patient who has just arrived on the orthopedic unit after a right above-the-knee amputation with an immediate prosthetic fitting. Which of the following actions should the nurse implement first?
- A. Place the patient in a prone position.
- B. Check the surgical site for hemorrhage.
- C. Remove the prosthesis and wrap the site.
- D. Keep the residual leg elevated on a pillow.
Correct Answer: B
Rationale: The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.
The nurse is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg. Which of the following observations indicates that the patient can safely ambulate independently?
- A. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
- B. The patient advances the right leg and both crutches together and then advances the left leg.
- C. The patient moves the left crutch with the left leg and then the right crutch with the right leg.
- D. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.
Correct Answer: B
Rationale: When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.
The nurse is preparing a patient who had an above-the-knee amputation for discharge. Which of the following patient statements indicates that the nurse's discharge teaching has been effective?
- A. I should lie on my abdomen for 30 minutes three or four times a day.
- B. I should elevate my residual limb on a pillow two or three times a day.
- C. I should change the limb sock when it becomes soiled or stretched out.
- D. I should use lotion on the stump to prevent drying and cracking of the skin.
Correct Answer: A
Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.
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.
In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident?
- A. Obtain x-rays.
- B. Check pedal pulses.
- C. Assess lung sounds.
- D. Take blood pressure.
- E. Apply splint to the leg.
- F. Administer tetanus prophylaxis.
Correct Answer: C,D,B,E,A,F
Rationale: The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.