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While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
- A. Risk for Infection
- B. Risk for Peripheral Neurovascular Dysfunction
- C. Unilateral Neglect
- D. Disturbed Kinesthetic Sensory Perception
Correct Answer: B
Rationale: The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction. There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.
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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.
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.
A patient is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
- A. Risk for Impaired Skin Integrity
- B. Risk for Falls
- C. Risk for Imbalanced Fluid Volume
- D. Risk for Aspiration
Correct Answer: A
Rationale: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.
A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions?
- A. Improving the patient's level of function
- B. Helping the patient come to terms with limitations
- C. Administering medications safely
- D. Improving the patient's adherence to treatment
Correct Answer: A
Rationale: Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?
- A. Subcutaneous emphysema
- B. Skin breakdown
- C. Compartment syndrome
- D. Disuse syndrome
Correct Answer: C
Rationale: Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.