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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.
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A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching?
- A. I'll need to keep several pillows between my legs at night.
- B. I need to remember not to cross my legs. It's such a habit.
- C. The occupational therapist is showing me how to use a sock puller to help me get dressed.
- D. I will need my husband to assist me in getting off the low toilet seat at home.
Correct Answer: D
Rationale: To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
- A. Knots in the rope should not be resting against pulleys.
- B. Weights should rest against the bed rails.
- C. The end of the limb in traction should be braced by the footboard of the bed.
- D. Skeletal traction may be removed for brief periods to facilitate the patient's independence.
Correct Answer: A
Rationale: Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.
The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?
- A. Balanced traction can be applied at night and removed during the day.
- B. Balanced traction allows for greater patient movement and independence than other forms of traction.
- C. Balanced traction is portable and may accompany the patient's movements.
- D. Balanced traction facilitates bone remodeling in as little as 4 days.
Correct Answer: B
Rationale: Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 4 days.
A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action?
- A. Administer pain medication as ordered.
- B. Assess the surgical site and the affected extremity.
- C. Reassure the patient that pain is a direct result of increased activity.
- D. Assess the patient for signs and symptoms of systemic infection.
Correct Answer: B
Rationale: Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he's anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.
The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
- A. Increased warmth of the calf
- B. Decreased circumference of the calf
- C. Loss of sensation to the calf
- D. Pale-appearing calf
Correct Answer: A
Rationale: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.