Nokea
Which action should the nurse take to ensure proper traction management?
- A. Inspect the client's skin when performing a bed bath.
- B. Apply oxygen by nasal cannula.
- C. Provide pin care by using alcohol wipes to clean the sites.
- D. Ensure that the weights remain freely hanging at all times.
Correct Answer: D
Rationale: Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.
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A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?
- A. Pain of 4 on a scale of 0 to 10.
- B. Numbness in the extremity.
- C. Swollen extremity at the injury site.
- D. Feeling cold while lying in bed.
Correct Answer: B
Rationale: The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling are expected after a fracture and can be treated with comfort measures. Feeling cold can be addressed with additional blankets or increasing the room temperature.
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 assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- A. Stability to maintain abduction of the affected arm for more than 90 seconds.
- B. Shoulder pain that is relieved with overhead stretches and at night.
- C. Inability to initiate or maintain abduction of the affected arm at the shoulder.
- D. Referred pain to the shoulder and arm opposite the affected shoulder.
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.
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.
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
- A. Edema "? Increased capillary permeability
- B. Pallor "? Increased blood flow to the area
- C. Unequal pulses "? Increased production of lactic acid
- D. Cyanosis "? Anaerobic metabolism
- E. Tingling "? A release of histamine
Correct Answer: A,C,D
Rationale: Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, unequal pulses are caused by increased production of lactic acid, and cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, not increased blood flow, and tingling is caused by increased tissue pressure, not histamine release.