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23 Cards in this Set
- Front
- Back
- 3rd side (hint)
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1. Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? |
* Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. * Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. * Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. * Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. |
Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.Correct Correct: Vital sign assessment is a skill that is within the role of the UAP. |
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2. The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? Select all that apply. |
* Occupational therapist * Physical therapist * Psychologist * Respiratory therapist * Speech therapist |
* Occupational therapist Correct * Physical therapist Correct * Psychologist Correct * Respiratory therapist * Speech therapist Correct Feedback: Correct: An occupational therapist will help to enable the client to become more independent in performing activities of daily living. Incorrect Feedback: Incorrect: The client has an amputation and does not have a respiratory condition that warrants collaborative care with a respiratory therapist. |
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3. The nurse plans to refer a client with an amputation and the client's family to which community resource? |
* American Amputee Society (AAS) * Amputee Coalition of America (ACA) * Community Workers for Amputees (CWA) * National Amputee of America Society (NAAS) |
Amputee Coalition of America (ACA) Correct Correct: The ACA is an available resource for clients with amputations and supports them and their families. |
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4. The client is brought to the emergency department (ED) via ambulance after a motor vehicle accident. What condition will the nurse assess for first? |
* Bleeding * Head injury * Pain * Respiratory distress |
Respiratory distress Correct Correct: The client is first assessed for respiratory distress, and any oxygen interventions are instituted accordingly. |
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5. The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention will the nurse implement? |
* Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile cotton-tipped swab * Using strict aseptic technique when cleaning the site * Leaving the site open to the air to keep it dry * Assisting the client to shower daily and pat the wound site dry |
Using strict aseptic technique when cleaning the site Correct Correct: Using aseptic technique is the best way to prevent infection. |
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6. The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? |
* Avoid contact sports. * Avoid rigorous exercise. * Wear helmets when riding a motorcycle. * Avoid driving in inclement weather. |
Wear helmets when riding a motorcycle. Correct Correct: Those who ride motorcycles or bicycles should wear helmets to prevent head injury. |
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7. The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which intervention will the nurse implement for this client? |
* Keep the client's heels off the bed at all times. * Reposition the client every 3 to 4 hours. * Administer preventive pain medication during deep-breathing exercises. * Prohibit the use of antiembolic stockings. |
Keep the client's heels off the bed at all times. Correct Correct: Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. |
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8. The client is recovering from an above-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? |
* "My spouse will be the only person to change my dressing." * "I can't believe that this has happened to me. I can't stand to look at it." * "I do not want any visitors while I'm in the hospital!" * "It will take me some time to get used to this." |
"It will take me some time to get used to this." Correct Correct: This statement indicates that the client is expressing acceptance and effective coping. |
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9. Which intervention will the nurse suggest to a client with a leg amputation to help cope with loss of the limb? |
* Talking with an amputee close to the client's age who has had the same type of amputation * Drawing a picture of how the client sees himself or herself * Talking with a psychiatrist about the amputation * Engaging in diversional activities to avoid focusing on the amputation |
Talking with an amputee close to the client's age who has had the same type of amputationCorrect Correct: Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. |
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10. The client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? |
* "Simple fracture involves a break in the bone, with skin contusions." * "Compound fracture does not extend through the skin." * "Simple fracture is accompanied by damage to the blood vessels." * "Compound fracture, grade I, involves minimal skin damage." |
"Compound fracture, grade I, involves minimal skin damage." Correct Correct: A grade I compound fracture involves minimal damage to the skin. |
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11. Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? |
* "A callus is quickly deposited and transformed into bone." * "A hematoma forms at the site of the fracture." * "Calcium and vascular proliferation surround the fracture site." * "Granulation tissue reabsorbs the hematoma and deposits new bone." |
"A hematoma forms at the site of the fracture." Correct Correct: In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. |
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12. Which typical clinical manifestation does the nurse expect to observe for a client with a right tibial fracture? |
* Flaccid extremity * Crepitation of extremity * Mild pain * No evidence of edema |
Crepitation of extremity Correct Correct: On assessment, crepitation (a continuous grating sound created by bone fragments) may be heard when the affected extremity is moved. |
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13. The client's left arm is placed in a plaster cast. Which assessment will the nurse perform before the client is discharged? |
* Assess that the cast is dry. * Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. * Check the fit of the cast by inserting a tongue blade between the cast and the skin. * Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds. |
Assess that the cast is dry. Correct Correct: The cast must be dry and free of cracking and crumbling. |
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14. The client is in skeletal traction. Which nursing intervention ensures proper care of this client? |
* Ensure that weights are attached to the bed frame or placed on the floor. * Ensure that pins are not loose, and tighten as needed. * Inspect the skin at least every 8 hours. * Remove the traction weights only for bathing. |
Inspect the skin at least every 8 hours. Correct Correct: Inspect the skin every 8 hours for signs of irritation, inflammation, or actual skin breakdown. |
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15. An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle accident. Which pain medication does the nurse anticipate will be requested for this client? |
* Cyclobenzaprine (Flexeril) * Ibuprofen (Advil, Motrin, Dolgesic, others) * Meperidine (Demerol) * Patient-controlled analgesia (PCA) with morphine |
Patient-controlled analgesia (PCA) with morphine Correct Correct: Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries. |
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16. A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? Select all that apply. |
* Acute compartment syndrome (ACS) * Fat embolism syndrome (FES) * Congestive heart failure * Urinary tract infection (UTI) * Osteomyelitis |
* Acute compartment syndrome (ACS) Correct * Fat embolism syndrome (FES) Correct * Congestive heart failure * Urinary tract infection (UTI) * Osteomyelitis Correct Correct Feedback: Correct: Acute compartment syndrome (ACS) is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. Incorrect Feedback: Incorrect: Congestive heart failure is not a potential complication for this client. Pulmonary embolism is a potential complication for venous thromboembolism, which can occur with fracture. Awarded 2.0 points out of 3.0 possible points. |
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17. The nurse prepares to perform a neurovascular assessment on the client with closed multiple fractures of the right humerus. Which technique will the nurse use? |
* Inspect the abdomen for tenderness and bowel sounds. * Auscultate lung sounds. * Assess the level of consciousness and ability to follow commands. * Assess sensation of the right upper extremity. |
Assess sensation of the right upper extremity. Correct Correct: Assessing sensation of the right upper extremity is part of a focused neurovascular assessment for the client with multiple fractures of the right humerus. |
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18. The client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction will the nurse plan to include in this client's teaching plan? |
* Use pain medication as prescribed to control pain. * Clean the pin site when any drainage is noticed. * Wear the same clothing that is normally worn. * Apply Neosporin (bacitracin, neomycin, and polymyxin B) if signs or symptoms of infection develop around pin sites. |
Use pain medication as prescribed to control pain. Correct Correct: The client should be taught the correct use of prescribed pain medication to control pain adequately. |
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19. The client has undergone an elective below-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? |
* Observation of a large amount of serosanguineous or bloody drainage * Mild to moderate pain controlled with prescribed analgesics * Absence of erythema and tenderness at the surgical site * Ability to flex and extend the right knee |
Observation of a large amount of serosanguineous or bloody drainage Correct Correct: A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. |
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20. The client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? |
* Surgical repair of the rotator cuff * Prescribed exercises of the affected arm * Sling for the affected arm * Patient-controlled analgesia with morphine |
Sling for the affected arm Correct Correct: The conservative treatment for this client is to place the injured arm in a sling or immobilizer. |
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21. The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? |
* Balanced skin traction * Buck's traction * Overhead traction * Plaster traction |
Buck's traction Correct Correct: Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. |
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22. A client is admitted to the emergency department after a motorcycle accident with a compound fracture of the left femur. Which action will be most essential for the nurse to take first? |
* Check the dorsalis pedis pulses. * Immobilize the left leg with a splint. * Administer the prescribed analgesic. * Place a dressing on the affected area. |
Check the dorsalis pedis pulses. Correct Correct: The first action should be to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome (ACS), which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. |
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23. Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the physician? |
* Thighs have multiple oozing abrasions. * Serum potassium level is 7 mEq/L. * The client is describing pain at a level 4 (0 to 10 scale). * Hemoglobin level is 12.0 g/dL. |
Serum potassium level is 7 mEq/L. Correct Correct: The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further renal damage or cardiac dysrhythmias. |
