The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the
... [Show More] purpose of the compression sock on my stump?" Which statement by the nurse is appropriate?
Choose One
1. "The compression sock on the stump will increase your balance when crutch walking."
2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump."
3. "A compression sock is applied to shape the stump smaller and rounder on the bottom."
4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."
3
Rationale
3. Correct: Wrapping the stump with an ace bandage will assist in configuring the stump into a cone shape. The cone shape is smaller and rounded on the bottom. The cone shaped stump will result in the stump fitting easier into the prosthesis.
1. Incorrect: The compression sock will not increase the client's balance when crutch walking. The compression sock will assist in shaping the stump.
2. Incorrect: This is an incorrect statement. The nurse's interventions to decrease phantom pain would include diversional activity and administering the prescribed analgesic.
4. Incorrect: Applying a compression sock to the right stump is not an appropriate intervention to decrease the risk of a DVT. The risk for a DVT after surgery is increased in the left leg. Interventions to decrease a DVT are to move the extremities frequently and increasing fluid intake.
Which interventions would the nurse implement for a client with a right total hip arthroplasty performed 6 hours ago?
Select All That Apply
1. Remove the abductor pillow.
2. Place a pillow under both knees.
3. Position the feet with the toes pointed upward.
4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses.
5. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.
3, 4
Rationale
3. & 4. Correct: These are correct interventions. The feet should be placed in a neutral rotation position with the toes pointed to the ceiling. This positioning of the feet prevents the hips from rotating inwardly or outwardly. If the hips are not positioned appropriately, there is a postoperative risk for dislocation of the hip. The postoperative neurovascular assessment of the right leg includes evaluating the client's popliteal, dorsalis pedis, and posterior tibial pulses. The nurse should evaluate the peripheral pulses distal to the hip. The primary healthcare provider should be notified of any alterations in the peripheral pulses.
1. Incorrect: The abduction pillow is not removed within 6 hours of a total hip arthroplasty. This is an inappropriate intervention. The abduction pillow is attached to the legs to prevent adduction of the hips to decrease the risk of a dislocation of the surgical hip.
2. Incorrect: The nurse should not place a pillow under either knee. The pillows would decrease the circulation to the lower extremities and increase the risk factor for deep vein thrombosis (DVT). Also, an abduction pillow is attached to the lower extremities.
5. Incorrect: The normal hemoglobin range for a male client is 14-15 g/dL (8.7-11.2 mmol/L). The client's hemoglobin level is 15g/dL (9.31mmol/L). Since the client's hemoglobin level is within normal range, the nurse will not notify the primary healthcare provider.
A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved?
Choose One
1. Respirations - 24.
2. Oxygen saturation - 94%.
3. Arterial blood gas - pH 7.34.
4. No infiltrates noted on chest x-ray.
4
Rationale
4. Correct: A fat embolism is caused by droplets of bone marrow fat that is released into the venous system. The droplets may lodge in the lungs. An x-ray of the lungs with the bone marrow fat will have a "snowstorm" appearance. A chest x-ray that does not identify any filtrates and does not have a "snowstorm" appearance is indicative the fat embolus is decreasing in size or completely resolved.
1. Incorrect: A respiratory rate of 24 is not within the normal range of respirations for an adult. If FES has resolved, you would expect the respiratory rate to be normal.
2. Incorrect: Oxygen saturation is the percentage of hemoglobin saturated with oxygen. A oxygen saturation value of 94% is not within the normal range of 95% to 100%. If FES has resolved, you would expect the oxygen saturation percentage to be normal.
3 Incorrect: The normal pH arterial blood gas range is 7.35-7.45. The client's pH level of 7.34 is not within the normal pH range. It is acidotic. The body regulates the pH level by changing the body's CO2, bicarbonate, oxygen levels. This lab value is not reflective of the resolution of a FES.
A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome?
Select All That Apply
1. The pain is located at the elbow area.
2. The prescribed opioid does not relieve the pain.
3. When forearm is elevated, the swelling in the forearm is reduced.
4. The pain in the forearm is described as a 9 on a 10 scale and throbbing.
5. When placing a cold compress on the forearm, the pain level is reduced.
2, 4
Rationale
2. & 4. Correct: Compartment syndrome occurs when swelling occurs within the compartment. This results in increased pressure on the capillaries, nerves, and muscles in the compartment. The pain is very intense. The client is expressing pain at a 9 on a 10 scale and throbbing. The pain is also unrelieved by opioid administration.
1. Incorrect: The location of pain at the elbow area does not indicate the presence of compartment syndrome. The pain related to compartment syndrome would not occur in the elbow. The swelling and bleeding will occur in the compartment of the forearm due to the swelling or bleeding.
3. Incorrect: The swelling will not be reduced by elevating the forearm as result of the constant increased pressure in the compartment.
5. Incorrect: Applying a cold compress on the forearm that decreases the swelling is not a symptom of compartment syndrome. The increased pressure in the compartment results in a decrease of the blood flow to the muscles and nerves.
A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement?
Choose One
1. Physically reduce the fracture.
2. Externally rotate the left leg.
3. Position the bed into a high Fowler's position.
4. Cover the fractured site with a sterile dressing.
4
Rationale
4. Correct: An open fracture is when the bone has broken the skin and underlying soft tissue, and the bone is protruding from the wound. The nurse should cover the fracture site with a sterile dressing to prevent contamination of deeper tissues.
1. Incorrect: The leg was splinted as a temporary emergency intervention. Upon arrival in the emergency room, the fracture should not be reduced by the nurse. Once the skin has been broken at the fracture site, the wound is a portal of entry for contaminants. A surgical procedure is performed to clean the wound and the bone.
2. Incorrect: If the nurse externally rotates the left leg, there is an increased risk of additional trauma to the tissues from the movement of the fracture bone. Also, there is a risk of the bone slipping into the wound from the external rotation.
3. Incorrect: Placing the client in high Fowlers position is not an appropriate intervention. The fractured site and/or limb should be elevated.
Which assessment findings would indicate to the nurse that a client may have a fracture?
Select All That Apply
1. Swelling
2. Deformity
3. Crepitus
4. Discoloration
5. Tenting of skin
1, 2, 3, 4
Rationale
1., 2., 3. & 4. Correct: Swelling, deformity, crepitus, and discoloration are signs of a fracture. The swelling is caused by fluids and blood that move into the soft tissues. The leaking of blood from the soft tissue or from the bone will result in a discoloration or bruising at the injury site. The most accurate sign of a broken bone is deformity of the bone. An example would be when a bone is bending in an inappropriate direction.
5. Incorrect: Tenting of the skin is not a sign of a fracture. Tenting is the slow return of skin after the skin has been pinched. If tenting is present, this indicates that the client is possibly dehydrated.
A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see?
Select All That Apply
1. Pain
2. Foot drop
3. Muscle spasm
4. Bone displacement
5. Itching under the straps
1, 3, 4
Rationale
1., 3., & 4. Correct: The purpose of traction is to stabilize and realign bone fractures and reduce pain. If the skeletal traction is interrupted by losing the traction on the bone, the result may include pain, muscle spasm, and bone displacement.
2. Incorrect: Foot drop is the weakness or paralysis of the muscles that lift the front part of the foot. Causes of foot drop may include; nerve injury, muscle or nerve disorders, brain and spinal cord disorders, and immobility.
5. Incorrect: The client would not experience any itching under any straps or cords due to the accidental release of the skeletal traction.
The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included?
Select All That Apply
1. Rest cast on a soft pillow.
2. Keep the cast uncovered until air dried.
3. Mark the cast if there is breakthrough bleeding.
4. Place ice packs on side of the cast for first 24 hours.
5. Use the palms of hands when moving the cast for first 6 hours.
1, 2, 3, 4
Rationale
1., 2., 3., & 4. Correct: Until the cast has dried completely, the cast care instructions are to prevent indentations on the cast, reduce swelling, and evaluate any breakthrough bleeding.
5. Incorrect: To prevent indentations in the plaster cast, the cast should be moved with the palms of hands for first 24 to 72 hours.
The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement?
Select All That Apply
1. Perform pin care daily.
2. Rinse pins with water.
3. Clean with chlorhexidine.
4. Dry the area with clean gauze.
5. Monitor pin site every 10 hours.
1, 3
Rationale
1., & 3. Correct: Pin care is prescribed 48 to 72 hours after insertion. The pin care is initiated once a day. Chlorhexidine is prescribed to clean the pin insertion site.
2. Incorrect: The pins are rinsed with sterile saline and not water.
4. Incorrect: The area around the pin site is dried with sterile gauze. The use of clean gauze is not appropriate.
5. Incorrect: The pin site is assessed. Every 10 hours is not often enough to monitor for infection.
The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement?
Choose One
1. "The crutches are adjusted according to my height."
2. "I will support my weight on the hand grips when not walking."
3. "I plan to place my affected leg on the step first when ascending stairs."
4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."
3
Rationale
3. Correct: This statement is incorrect and further client teaching is needed. When going up stairs, the client should lead with the unaffected leg. The unaffected leg will provide the support required to then move the affected leg to the step.
1. Incorrect: The crutches should be adjusted according to the client's height and arm length. The top of the crutches should be approximately 1 to 2 inches under the axilla. The hips should be even with the hand grips. Also, the crutch length should be measured from the client's axilla to approximately 6 inches in front of the toe. This is a true statement.
2. Incorrect: If the weight is supported by placing the top of the crutches against the axilla, then brachial nerve damage will occur. To prevent the damage to the brachial nerve the hands rest on the hand grips when resting. This is a correct statement by the client.
4. Incorrect: To prevent damage to the brachial nerve, the client should position the crutches 1 to 2 inches below the axilla when walking with crutches. With the shoulders relaxed the client should be able to also position 2 finger widths between the axilla and the crutch pads. [Show Less]