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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.
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An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?
- A. The presence of leg shortening
- B. The patient's complaints of pain
- C. Signs of neurovascular compromise
- D. The presence of internal or external rotation
Correct Answer: C
Rationale: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.
The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
- A. Encourage independence with ADLs whenever possible.
- B. Monitor the patient's nutritional status closely.
- C. Teach the patient to perform ankle and foot exercises within the limitations of traction.
- D. Administer clopidogrel (Plavix) as ordered.
Correct Answer: C
Rationale: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.
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.
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.
A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient's plan of care. What intervention is most justified in the care of this patient?
- A. Administration of prophylactic antibiotics
- B. Total parenteral nutrition (TPN)
- C. Use of a pressure-relieving mattress
- D. Use of a Foley catheter until discharge
Correct Answer: C
Rationale: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.