Nokea
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.
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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 with ulnar drift caused by rheumatoid arthritis (RA) who is scheduled for an arthroplasty of the hand. Which of the following patient statements indicate realistic expectation for the surgery?
- A. I will be able to use my fingers to grasp objects better.
- B. I will not have to do as many hand exercises after the surgery.
- C. This procedure will prevent further deformity in my hands and fingers.
- D. My fingers will appear more normal in size and shape after this surgery.
Correct Answer: A
Rationale: The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.
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.
Before assisting a patient with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement?
- A. Administer the ordered oral opioid pain medication.
- B. Instruct the patient about the benefits of ambulation.
- C. Ensure that the incisional drain has been discontinued.
- D. Change the hip dressing and document the wound appearance.
Correct Answer: A
Rationale: The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.
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.