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These symptoms represent early warning signs of acute compartment syndrome. Which action should the nurse take first?
- A. Assess the pedal pulses.
- B. Apply oxygen by nasal cannula.
- C. Increase the IV flow rate.
- D. Loosen the traction.
Correct Answer: A
Rationale: These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesia precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.
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A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client's risk for infection?
- A. Wash the traction lines and sockets once a day.
- B. Release traction tension for 30 minutes twice a day.
- C. Do not place the traction weights on the floor.
- D. Schedule for pin care to be provided every shift.
Correct Answer: D
Rationale: To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client's skin, so these do not need to be washed. Releasing traction tension requires a prescription, and placing weights on the floor does not directly decrease infection risk.
An emergency department nurse stages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?
- A. Remove the medical alert bracelet from the fractured arm.
- B. Immobilize the arm by splinting the fractured site.
- C. Apply a sling to support the fractured arm.
- D. Cover any open areas with a sterile dressing.
Correct Answer: A
Rationale: A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed to ensure client safety.
A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery. Which actions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Elevate heels off the bed with a pillow.
- B. Ambulate the client on the first postoperative day.
- C. Use an abduction pillow to prevent hip subluxation.
- D. Re-position the client every 2 hours.
- E. Push the client's patient-controlled analgesia button.
Correct Answer: A,B,C,D
Rationale: Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown, ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should never push the patient-controlled analgesia button for the client.
A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
- A. Immobilize the client's arm.
- B. Assess the client's distal pulse.
- C. Monitor for signs of infection.
- D. Administer prescribed steroids.
Correct Answer: A
Rationale: A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.)
- A. Frequently assess the ergonomics of the equipment being used.
- B. Take breaks to stretch fingers and wrists during working hours.
- C. Perform wrist exercises to strengthen muscles.
- D. Adjust activities to increase pain and swelling in wrists.
- E. Use wrist splints during repetitive tasks.
Correct Answer: A,B,C,E
Rationale: To prevent carpal tunnel syndrome, the nurse should teach the client to assess the ergonomics of their workspace, take breaks to stretch fingers and wrists, perform wrist exercises to strengthen muscles, and use wrist splints during repetitive tasks. Adjusting activities to increase pain and swelling would worsen the condition and should not be recommended.