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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.
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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 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.
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 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.
The nurse is caring for a patient who has a cast in place after fracturing the radius and the patient asks when the cast can be removed. Which of the following information related to the length of time that the cast will need to remain in place should the nurse tell the patient?
- A. Several months
- B. At least 3 weeks
- C. Until swelling of the wrist has resolved
- D. Until x-rays show complete bony union
Correct Answer: B
Rationale: Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.