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Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply.
- A. Apply an immobilizer snugly to prevent edema.
- B. Apply an ice pack for 10 minutes and remove for 20 minutes.
- C. Place the extremity in the dependent position to allow drainage.
- D. Obtain an x-ray of the ankle after applying the immobilizer.
- E. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.
Correct Answer: B,D,E
Rationale: Ice reduces swelling, x-ray confirms fracture, and tetanus prevents infection in open fractures. Tight immobilizers risk neurovascular compromise, and dependent positioning worsens edema.
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The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
How can the nurse best support the wet cast while the physician wraps the arm with rolls of wet plaster?
- A. By using a soft mattress
- B. By resting it on a firm surface
- C. By using the client's knee on the fingers
- D. By using the palms of the hands
Correct Answer: D
Rationale: Using the palms of the hands to support the wet cast prevents indentations that could cause pressure points, ensuring the cast maintains its shape. A soft mattress or fingers may deform the cast, and a firm surface is less precise.
The nurse identifies a concept of impaired mobility for a male client with degenerative disk disease. Which assessment data best support this concept?
- A. The client reports a history of chronic back pain and multiple back surgeries.
- B. The client reports that taking NSAIDs caused the development of peptic ulcers.
- C. The client reports a three (3)-year history of difficulty initiating a urinary stream.
- D. The client states he fell a year ago and had to have a cast on the right arm for a month.
Correct Answer: A
Rationale: Chronic back pain and surgeries directly impair mobility in degenerative disk disease. Ulcers, urinary issues, and past arm fractures are unrelated to current mobility.
The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help prevent on-the-job injuries?
- A. Increase sodium and potassium in the diet during the winter months.
- B. Use the large thigh muscles when lifting and hold the weight near the body.
- C. Use soft-cushioned chairs when performing desk duties.
- D. Have the employee arrange for assistance with household chores.
Correct Answer: B
Rationale: Using thigh muscles and keeping weight close to the body promotes proper lifting mechanics, reducing back strain. Diet, chair cushioning, and household chores are unrelated to workplace injury prevention.
The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?
- A. Positions the client so the client's feet stay clear of the bottom of the bed
- B. Checks ropes so that they are positioned in the wheel groves of the pulleys
- C. Removes weights from ropes until the weights hang free of the bed frame
- D. Performs pin site care with chlorhexidine solution once during the 8-hour shift
Correct Answer: C
Rationale: C. Weights should be hanging freely, but weights should never be removed (unless a life-threatening situation occurs) because removal could result in injury and defeats the purpose of the traction. The lengths of the ropes need to be adjusted so the weights do not rest on the bed frame.