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WHICH INFORMATION WOULD THE NURSE TEACH OLDER ADULTS AT A COMMUNITY
RECREATION CENTER ABOUT
WAYS TO PREVENT FRACTURES?
A. TACK DOWN SCATTER RUGS ON THE FLOOR IN THE HOME.
B. EXPECT MOST FALLS TO HAPPEN OUTSIDE THE HOME IN THE YARD.
C. BUY SUPPORTIVE NONSKID SHOES THAT ARE COMFORTABLE TO WEAR.
D. GET INSTRUCTION IN RANGE-OF-MOTION EXERCISES FROM A PHYSICAL THERAPIST.
BUY SUPPORTIVE NONSKID SHOES THAT ARE COMFORTABLE TO WEAR.
COMFORTABLE NONSKID SHOES WITH GOOD SUPPORT WILL HELP DECREASE THE RISK
FOR FALLS. SCATTER RUGS
SHOULD BE ELIMINATED, NOT JUST TACKED DOWN. ACTIVITIES OF DAILY LIVING PROVIDE
EXERCISE FOR
ACTIVE ADULTS; RANGE-OF-MOTION DOES NOT NEED TO BE TAUGHT BY A PHYSICAL
THERAPIST. FALLS INSIDE
THE HOME ARE RESPONSIBLE FOR MANY INJURIES.
A FACTORY LINE WORKER HAS DEVELOPED REPETITIVE STRAIN INJURY IN THE LEFT
ELBOW. WHICH TOPIC
WOULD THE NURSE PLAN TO INCLUDE IN PATIENT TEACHING?
A. SURGICAL OPTIONS
B. ELBOW INJECTIONS
C. WEARING A LEFT WRIST SPLINT
D. MODIFYING ARM MOVEMENTS
MODIFYING ARM MOVEMENTS
TREATMENT FOR REPETITIVE STRAIN INJURY INCLUDES CHANGING THE ERGONOMICS OF
THE ACTIVITY. ELBOW
INJECTIONS AND SURGERY ARE NOT INITIAL OPTIONS FOR THIS TYPE OF INJURY. A WRIST
SPLINT MIGHT BE
USED FOR HAND OR WRIST PAIN.
WHICH RECOMMENDATION WOULD THE OCCUPATIONAL HEALTH NURSE PROVIDE TO A
PATIENT WHOSE JOB
INVOLVES MANY HOURS OF TYPING?
A. OBTAIN A KEYBOARD PAD TO SUPPORT THE WRIST.
B. DO STRETCHING EXERCISES BEFORE STARTING WORK.
C. WRAP THE WRISTS WITH COMPRESSION BANDAGES EACH MORNING.
D. AVOID USING NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS).
OBTAIN A KEYBOARD PAD TO SUPPORT THE WRIST.
REPETITIVE STRAIN INJURIES CAUSED BY PROLONGED WORK AT A KEYBOARD CAN BE
PREVENTED BY USING A
PAD TO KEEP THE WRISTS IN A STRAIGHT POSITION. STRETCHING EXERCISES DURING THE
DAY MAY BE
HELPFUL, BUT THESE WOULD NOT BE NEEDED BEFORE STARTING WORK. USE OF A
COMPRESSION BANDAGE IS
NOT NEEDED, ALTHOUGH A SPLINT MAY BE USED FOR CARPAL TUNNEL SYNDROME.
NSAIDS ARE
APPROPRIATE TO DECREASE SWELLING.
WHICH DISCHARGE INSTRUCTION WOULD THE EMERGENCY DEPARTMENT NURSE
INCLUDE FOR A PATIENT WITH
A SPRAINED ANKLE?
A. KEEP THE ANKLE LOOSELY WRAPPED WITH GAUZE.
B. APPLY A HEATING PAD TO REDUCE MUSCLE SPASMS.
RETURN TO TENNIS AFTER REHABILITATION.
THE NURSE WOULD INSTRUCT A PATIENT WITH A NONDISPLACED FRACTURED LEFT
RADIUS THAT THE CAST WILL
NEED TO REMAIN IN PLACE FOR WHAT AMOUNT OF TIME?
A. TWO WEEKS
B. AT LEAST SIX WEEKS
C. UNTIL SWELLING OF THE WRIST HAS RESOLVED
D. UNTIL X-RAYS SHOW COMPLETE BONY UNION
AT LEAST SIX WEEKS
BONE HEALING STARTS IMMEDIATELY AFTER THE INJURY, BUT BECAUSE OSSIFICATION
DOES NOT BEGIN UNTIL
3 WEEKS AFTER INJURY, THE CAST WILL NEED TO BE WORN FOR MORE THAN 3 WEEKS.
COMPLETE UNION
MAY TAKE UP TO 1 YEAR. RESOLUTION OF SWELLING DOES NOT INDICATE BONE HEALING.
THE NURSE IS CARING FOR A PATIENT WHO HAS A PELVIC FRACTURE AND AN EXTERNAL
FIXATION DEVICE.
WHICH METHOD WOULD THE NURSE USE TO ASSESS PRESSURE AREAS AND PROVIDE SKIN
CARE TO THE
PATIENT'S BACK AND SACRUM?
A. ASK THE PATIENT TO TURN TO THE SIDE INDEPENDENTLY.
B. DEFER BACK ASSESSMENT UNTIL THE PATIENT IS AMBULATORY.
C. HAVE THE PATIENT LIFT THE BACK AND BUTTOCKS USING A TRAPEZE BAR.
D. ROLL THE PATIENT OVER TO THE SIDE BY PUSHING ON THE PATIENT'S HIPS.
HAVE THE PATIENT LIFT THE BACK AND BUTTOCKS USING A TRAPEZE BAR.
THE PATIENT CAN LIFT THE BACK SLIGHTLY OFF THE BED BY USING A TRAPEZE. THE
PATIENT MAY FIND IT
VERY DIFFICULT TO TURN TO THE SIDE WITHOUT ASSISTANCE WHILE IN A FIXATOR
DEVICE. DELAYING
ASSESSMENT AND SKIN CARE MAY PUT THE PATIENT AT RISK FOR AN UNDETECTED
PRESSURE INJURY. PUSHING
ON THE PATIENT'S HIPS MAY CAUSE ADDITIONAL INJURY.
WHICH PATIENT STATEMENT INDICATES UNDERSTANDING OF THE NURSE'S TEACHING
ABOUT A NEW
SHORT-ARM SYNTHETIC CAST?
A. ―I CAN REMOVE THE CAST IN 4 WEEKS USING INDUSTRIAL SCISSOR S.‖
B. ―I SHOULD AVOID M OVING MY FINGERS UNTIL THE CAST IS REMOV ED.‖
C. ―I WILL APPLY AN ICE PACK TO THE CAST OVER THE FRACTURE SITE OFF AND ON FOR
24 HOURS.‖
D. ―I CAN USE A COTT ON-TIPPED APPLICATOR TO RUB LOTION ON ANY DRY AREAS
UNDER THE CAST.‖
―I WILL APPLY AN ICE PACK TO THE CAST OVER THE FRACTURE SITE OFF AND ON FOR 24
HOURS.‖
ICE APPLICATION FOR THE FIRST 24 HOURS AFTER A FRACTURE WILL HELP REDUCE
SWELLING AND CAN BE
PLACED OVER THE CAST. THE CAST IS TYPICALLY REMOVED IN THE OUTPATIENT SETTING.
THE PATIENT SHOULD
BE ENCOURAGED TO MOVE THE JOINTS ABOVE AND BELOW THE CAST. PATIENTS SHOULD
NOT INSERT OBJECTS
INSIDE THE CAST.
A PATIENT WHO IS TO HAVE NO WEIGHT BEARING ON THE LEFT LEG IS LEARNING TO USE
CRUTCHES. WHICH
MORPHINE. THE NURSE DETERMINES PULSES ARE FAINTLY PALPABLE AND THE FOOT IS
COOL TO THE TOUCH.
WHICH ACTION WOULD THE NURSE TAKE NEXT?
A. NOTIFY THE HEALTH CARE PROVIDER.
B. ASSESS THE INCISION FOR REDNESS.
C. REPOSITION THE LEFT LEG ON PILLOWS.
D. CHECK THE PATIENT'S BLOOD PRESSURE.
NOTIFY THE HEALTH CARE PROVIDER.
THE PATIENT'S CLINICAL MANIFESTATIONS SUGGEST POSSIBLE COMPARTMENT
SYNDROME AND DELAY IN
DIAGNOSIS AND TREATMENT MAY LEAD TO SEVERE FUNCTIONAL IMPAIRMENT. THE
DATA DO NOT SUGGEST
PROBLEMS WITH BLOOD PRESSURE OR INFECTION. ELEVATION OF THE LEG WILL
DECREASE ARTERIAL FLOW AND
FURTHER REDUCE PERFUSION
A PATIENT WITH A COMPLEX PELVIC FRACTURE FROM A MOTOR VEHICLE CRASH IS ON
BED REST. WHICH
ASSESSMENT FINDING INDICATES A POTENTIAL COMPLICATION OF THE FRACTURE?
A. THE PATIENT STATES THE PELVIS FEELS UNSTABLE.
B. THE PATIENT REPORTS PELVIC PAIN WITH PALPATION.
C. ABDOMEN IS DISTENDED AND BOWEL SOUNDS ARE ABSENT.
D. ECCHYMOSES ARE VISIBLE ACROSS THE ABDOMEN AND HIPS.
ABDOMEN IS DISTENDED AND BOWEL SOUNDS ARE ABSENT
THE ABDOMINAL DISTENTION AND ABSENT BOWEL SOUNDS MAY BE DUE TO
COMPLICATIONS OF PELVIC
FRACTURES SUCH AS PARALYTIC ILEUS OR HEMORRHAGE OR TRAUMA TO THE BLADDER,
URETHRA, OR COLON.
PELVIC INSTABILITY, ABDOMINAL PAIN WITH PALPATION, AND ABDOMINAL BRUISING
WOULD BE EXPECTED
WITH THIS TYPE OF INJURY.
WHICH ACTION WOULD THE NURSE TAKE TO EVALUATE THE EFFECTIVENESS OF BUCK'S
TRACTION FOR A
PATIENT WHO HAS A FRACTURE OF THE RIGHT FEMUR?
A. ASSESS FOR HIP PAIN.
B. CHECK FOR CONTRACTURES.
C. PALPATE PERIPHERAL PULSES.
D. MONITOR FOR HIP DISLOCATION.
ASSESS FOR HIP PAIN.
BUCK'S TRACTION IS USED TO REDUCE PAINFUL MUSCLE SPASM. HIP CONTRACTURES AND
DISLOCATION ARE
UNLIKELY TO OCCUR IN THIS SITUATION. THE PERIPHERAL PULSES WILL BE ASSESSED, BUT
THIS DOES NOT
HELP IN EVALUATING THE EFFECTIVENESS OF BUCK'S TRACTION.
WE HAVE AN EXPERT-WRITTEN SOLUTION TO THIS PROBLEM!
A PATIENT WHO HAS A RIGHT LOWER LEG FRACTURE WILL BE DISCHARGED HOME WITH
AN EXTERNAL FIXATION
DEVICE IN PLACE. WHICH STATEMENT WOULD THE NURSE INCLUDING IN DISCHARGE
TEACHING?
A. ―CHECK AND CLEAN THE PIN INSERTION SIT ES DAILY.‖
B. ―REMAIN ON BED RE ST UNTIL BONE HEALIN G IS COMPLETE.‖
C. ―REMOVE THE EXTER NAL FIXATOR FOR YOUR DAILY SHOWER.‖
D. ―TAKE PROPHYLACTI C ANTIBIOTICS UNTIL THE FIXATOR IS REMOV ED.‖
―CHECK AND CLEAN THE PIN INSERTION SITES DAILY.‖
REPAIR OF A FRACTURED MANDIBLE?
A. ADMINISTRATION OF NASOGASTRIC TUBE FEEDINGS
B. HOW AND WHEN TO CUT THE IMMOBILIZING WIRES
C. THE IMPORTANCE OF HIGH-FIBER FOODS IN THE DIET
D. THE USE OF STERILE TECHNIQUE FOR DRESSING CHANGES
HOW AND WHEN TO CUT THE IMMOBILIZING WIRES
THE JAW WILL BE WIRED FOR STABILIZATION, AND THE PATIENT SHOULD KNOW WHAT
EMERGENCY
SITUATIONS REQUIRE THE WIRES TO BE CUT TO PROTECT THE AIRWAY. THERE ARE NO
DRESSING CHANGES FOR
THIS PROCEDURE. THE DIET IS LIQUID, AND PATIENTS ARE NOT ABLE TO CHEW HIGH-
FIBER FOODS. INITIALLY,
THE PATIENT MAY RECEIVE NASOGASTRIC TUBE FEEDINGS, BUT BY DISCHARGE, THE
PATIENT WILL SWALLOW
LIQUID THROUGH A STRAW.
WE HAVE AN EXPERT-WRITTEN SOLUTION TO THIS PROBLEM!
AFTER THE HEALTH CARE PROVIDER RECOMMENDS AMPUTATION FOR A PATIENT WHO
HAS NONHEALING
ISCHEMIC FOOT ULCERS, THE PATIENT TELLS THE NURSE THAT HE WOULD RATHER DIE
THAN HAVE AN
AMPUTATION. WHICH INITIAL RESPONSE WOULD THE NURSE PROVIDE?
A. ―YOU ARE UPSET, B UT YOU MAY LOSE THE FOOT EVENTUALLY.‖
B. ―MANY PEOPLE ARE ABLE TO FUNCTION WITH A FOOT PROSTHESIS.‖
C. ―TELL ME WHAT YOU KNOW ABOUT YOUR OPTI ONS FOR TREATMENT.‖
D. ―IF YOU DO NOT WA NT AN AMPUTATION, YOU DO NOT HAVE TO HAV E IT.‖
―TELL ME WHAT YOU KN OW ABOUT YOUR OPTION S FOR TREATMENT.‖
THE INITIAL NURSING ACTION SHOULD BE TO ASSESS THE PATIENT'S KNOWLEDGE AND
FEELINGS ABOUT THE
AVAILABLE OPTIONS. DISCUSSION OF THE PATIENT'S OPTION TO REFUSE THE PROCEDURE,
SERIOUSNESS OF THE
CONDITION, OR REHABILITATION AFTER THE PROCEDURE MAY BE APPROPRIATE AFTER
THE NURSE KNOWS MORE
ABOUT THE PATIENT'S CURRENT KNOWLEDGE AND EMOTIONAL STATE.
THE DAY AFTER A HAVING A RIGHT BELOW-THE-KNEE AMPUTATION, A PATIENT REPORTS
PAIN IN THE MISSING
RIGHT FOOT. WHICH ACTION IS MOST IMPORTANT FOR THE NURSE TO TAKE?
A. EXPLAIN THE REASONS FOR THE PAIN.
B. ADMINISTER PRESCRIBED ANALGESICS.
C. REPOSITION THE PATIENT TO ASSURE GOOD ALIGNMENT.
D. TELL THE PATIENT THAT THE PAIN WILL DIMINISH OVER TIME.
ADMINISTER PRESCRIBED ANALGESICS.
ACUTE PHANTOM LIMB SENSATION IS TREATED WITH ANALGESICS AS ANY OTHER TYPE
OF POSTOPERATIVE
PAIN WOULD BE TREATED. EXPLANATIONS OF THE REASON FOR THE LOCATION OF THE
PAIN MAY BE GIVEN.
ALIGNMENT IS IMPORTANT BUT IS UNLIKELY TO RELIEVE THE PAIN. ALTHOUGH THE PAIN
MAY DECREASE
OVER TIME, IT CURRENTLY REQUIRES TREATMENT.
WHICH STATEMENT BY A PATIENT WHO HAS HAD AN ABOVE-THE-KNEE AMPUTATION
INDICATES THE NURSE'S
DISCHARGE TEACHING HAS BEEN EFFECTIVE?
A. ―I SHOULD ELEVATE MY RESIDUAL LIMB ON A PILLOW 2 OR 3 TIME S A DAY.‖
B. ―I SHOULD LIE FLA T ON MY ABDOMEN FOR 30 MINUTES 3 OR 4 TI MES A DAY.‖
C. ―I SH OULD CHANGE THE LIMB SOCK WHEN IT BECOMES SOILED OR EACH WEEK. ‖
D. ―I SHOULD USE LOT ION ON THE STUMP TO PREVENT SKIN DRYING AND CRACKING.‖
C. TEACH ABOUT THE NEED TO AVOID WEIGHT BEARING FOR 4 WEEKS.
D. START PROGRESSIVE KNEE EXERCISES TO OBTAIN 90-DEGREE FLEXION.
START PROGRESSIVE KNEE EXERCISES TO OBTAIN 90-DEGREE FLEXION.
AFTER KNEE ARTHROPLASTY, ACTIVE OR PASSIVE FLEXION EXERCISES ARE USED TO
OBTAIN A 90-DEGREE
FLEXION OF THE KNEE. THE GOAL FOR EXTENSION OF THE KNEE WILL BE 180 DEGREES. A
COMPRESSION
BANDAGE IS USED TO HOLD THE KNEE IN AN EXTENDED POSITION AFTER SURGERY.
PROTECTED WEIGHT
BEARING IS TYPICALLY NOT ORDERED AFTER THIS PROCEDURE.
WE HAVE AN EXPERT-WRITTEN SOLUTION TO THIS PROBLEM!
A PATIENT WITH ULNAR DRIFT CAUSED BY RHEUMATOID ARTHRITIS (RA) IS SCHEDULED
FOR ARTHROPLASTY OF
SEVERAL JOINTS IN THE LEFT HAND. WHICH PATIENT STATEMENT TO THE NURSE
INDICATES A REALISTIC
EXPECTATION FOR THE SURGERY?
A. ―THIS PROCEDURE W ILL CORRECT THE DEFORMITIES IN MY FINGER S.‖
B. ―I WILL NOT HAVE TO DO AS MANY HAND EXERCISES AFTER THE SURGERY.‖
C. ―I WILL BE ABLE T O USE MY FINGERS WITH MORE FLEXIBILITY T O GRASP THINGS.‖
D. ―MY FINGERS WILL APPEAR MORE NORMAL IN SIZE AND SHAPE AF
―I WILL BE ABLE TO U SE MY FINGERS WITH MORE FLEXIBILITY TO G RASP THINGS.‖
THE GOAL OF HAND SURGERY IN RA IS TO RESTORE FUNCTION, NOT TO CORRECT FOR
COSMETIC DEFORMITY OR
TREAT THE UNDERLYING PROCESS. HAND EXERCISES WILL BE PRESCRIBED AFTER THE
SURGERY.
WHICH INFORMATION WOULD THE NURSE INCLUDE IN DISCHARGE INSTRUCTIONS FOR A
PATIENT WITH
COMMINUTED LEFT FOREARM FRACTURES AND A LONG-ARM CAST?
A. KEEP THE LEFT SHOULDER ELEVATED ON A PILLOW OR CUSHION.
B. AVOID NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS).
C. CALL THE HEALTH CARE PROVIDER FOR NUMBNESS OF THE HAND.
D. KEEP THE HAND IMMOBILE TO PREVENT SOFT TISSUE SWELLING.
CALL THE HEALTH CARE PROVIDER FOR NUMBNESS OF THE HAND.
INCREASED SWELLING OR NUMBNESS MAY INDICATE INCREASED PRESSURE AT THE
INJURY, AND THE HEALTH
CARE PROVIDER SHOULD BE NOTIFIED IMMEDIATELY TO AVOID DAMAGE TO NERVES AND
OTHER TISSUES. THE
PATIENT SHOULD BE ENCOURAGED TO MOVE THE JOINTS ABOVE AND BELOW THE CAST
TO AVOID STIFFNESS.
THERE IS NO NEED TO ELEVATE THE SHOULDER, ALTHOUGH THE FOREARM SHOULD BE
ELEVATED TO REDUCE
SWELLING. NSAIDS ARE APPROPRIATE TO TREAT MILD TO MODERATE PAIN AFTER A
FRACTURE.
WE HAVE AN EXPERT-WRITTEN SOLUTION TO THIS PROBLEM!
A PATIENT WHO SLIPPED AND FELL IN THE SHOWER AT HOME HAS A PROXIMAL LEFT
HUMERUS FRACTURE
IMMOBILIZED WITH A SLING. WHICH INTERVENTION WOULD THE NURSE INCLUDE IN THE
PLAN OF CARE?
A. USE SURGICAL NET DRESSING TO HANG THE ARM FROM AN IV POLE.
B. IMMOBILIZE THE FINGERS OF THE LEFT HAND WITH GAUZE DRESSINGS.
C. ASSESS THE LEFT AXILLA AND CHANGE ABSORBENT DRESSINGS AS NEEDED.
D. ASSIST THE PATIENT IN PASSIVE RANGE OF MOTION (ROM) FOR THE RIGHT ARM.
ASSESS THE LEFT AXILLA AND CHANGE ABSORBENT DRESSINGS AS NEEDED.
WHICH ACTION WOULD THE NURSE TAKE FIRST?
A. ADMINISTER PRESCRIBED PRN O2 AT 4 L/MIN.
B. CHECK THE PATIENT'S LEGS FOR SWELLING OR TENDERNESS.
C. NOTIFY THE HEALTH CARE PROVIDER ABOUT THE SYMPTOMS.
D. STAY WITH THE PATIENT AND OFFER REASSURANCE TO THE FAMILY.
ADMINISTER PRESCRIBED PRN O2 AT 4 L/MIN.
THE PATIENT'S CLINICAL MANIFESTATIONS AND HISTORY ARE CONSISTENT WITH A
PULMONARY EMBOLISM,
AND THE NURSE'S FIRST ACTION SHOULD BE TO ENSURE ADEQUATE OXYGENATION. THE
NURSE SHOULD OFFER
REASSURANCE TO THE PATIENT BUT MEETING THE PHYSIOLOGIC NEED FOR O2 IS A
HIGHER PRIORITY. THE
HEALTH CARE PROVIDER SHOULD BE NOTIFIED AFTER THE O2 IS STARTED AND PULSE
OXIMETRY OBTAINED
CONCERNING SUSPECTED FAT EMBOLISM OR VENOUS THROMBOEMBOLISM.
A PATIENT ARRIVED AT THE EMERGENCY DEPARTMENT AFTER TRIPPING OVER A RUG AND
FALLING AT HOME.
WHICH FINDING WOULD THE NURSE IDENTIFY AS MOST IMPORTANT TO COMMUNICATE
TO THE HEALTH CARE
PROVIDER?
A. THERE IS BRUISING AT THE SHOULDER AREA.
B. THE PATIENT REPORTS ARM AND SHOULDER PAIN.
C. THE RIGHT ARM APPEARS SHORTER THAN THE LEFT.
D. THERE IS DECREASED SHOULDER RANGE OF MOTION.
THE RIGHT ARM APPEARS SHORTER THAN THE LEFT.
A SHORTER LIMB AFTER A FALL INDICATES A POSSIBLE DISLOCATION, WHICH IS AN
ORTHOPEDIC EMERGENCY.
BRUISING, PAIN, AND DECREASED RANGE OF MOTION SHOULD ALSO BE REPORTED, BUT
THESE DO NOT
INDICATE EMERGENT TREATMENT IS NEEDED TO PRESERVE FUNCTION.
WE HAVE AN EXPERT-WRITTEN SOLUTION TO THIS PROBLEM!
A YOUNG ADULT ARRIVES IN THE EMERGENCY DEPARTMENT WITH ANKLE SWELLING AND
SEVERE PAIN AFTER
TWISTING THE ANKLE PLAYING BASKETBALL. WHICH PRESCRIBED ACTION WILL THE
NURSE IMPLEMENT FIRST?
A. SEND THE PATIENT FOR ANKLE X-RAYS.
B. GIVE ACETAMINOPHEN WITH CODEINE.
C. ADMINISTER ORAL NAPROXEN (NAPROSYN).
D. ELEVATE THE ANKLE AND APPLY AN ICE PACK.
ELEVATE THE ANKLE AND APPLY AN ICE PACK.
IMMEDIATE CARE AFTER A SPRAIN OR STRAIN INJURY INCLUDES ELEVATION AND
APPLICATION OF COLD TO
MINIMIZE SWELLING. THE OTHER ACTIONS WOULD BE TAKEN AFTER THE ANKLE IS
ELEVATED AND ICE IS
APPLIED.
FOR A PATIENT WHO HAS HAD RIGHT HIP ARTHROPLASTY, WHICH NURSING ACTION CAN
THE NURSE DELEGATE
TO EXPERIENCED ASSISTIVE PERSONNEL (AP)?
A. REPOSITION THE PATIENT EVERY 1 TO 2 HOURS.
B. ASSESS FOR SKIN IRRITATION ON THE PATIENT'S BACK.
C. TEACH THE PATIENT QUADRICEPS-SETTING EXERCISES.
D. DETERMINE THE PATIENT'S PAIN INTENSITY AND TOLERANCE.
REPOSITION THE PATIENT EVERY 1 TO 2 HOURS.
B. APPLY A COMPRESSION BANDAGE.
C. ASSESS LEG PULSES AND SENSATION.
D. PLACE ICE PACKS ON THE LOWER LEG.
ASSESS LEG PULSES AND SENSATION.
THE INITIAL ACTION BY THE NURSE WILL BE TO ASSESS CIRCULATION TO THE LEG AND
OBSERVE FOR ANY
EVIDENCE OF INJURY SUCH AS FRACTURES OR DISLOCATIONS. AFTER THE INITIAL
ASSESSMENT, THE OTHER
ACTIONS MAY BE APPROPRIATE BASED ON WHAT IS OBSERVED DURING THE
ASSESSMENT.
A PEDESTRIAN WHO WAS HIT BY A CAR IS ADMITTED TO THE EMERGENCY DEPARTMENT
WITH POSSIBLE RIGHT
LOWER LEG FRACTURES. WHICH INITIAL ACTION WOULD THE NURSE TAKE?
A. ELEVATE THE RIGHT LEG.
B. SPLINT THE LOWER LEG.
C. ASSESS THE PEDAL PULSES.
D. VERIFY TETANUS IMMUNIZATION.
ASSESS THE PEDAL PULSES.
THE INITIAL NURSING ACTION SHOULD BE ASSESSMENT OF THE NEUROVASCULAR
CONDITION OF THE INJURED
LEG. AFTER ASSESSMENT, THE NURSE MAY NEED TO SPLINT AND ELEVATE THE LEG BASED
ON THE
ASSESSMENT DATA. INFORMATION ABOUT TETANUS IMMUNIZATIONS SHOULD BE
OBTAINED IF THERE IS AN
OPEN WOUND.
A 60-YR-OLD PATIENT HAD OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR AN
OPEN, DISPLACED
TIBIAL FRACTURE. WHICH PATIENT PROBLEM WOULD THE NURSE IDENTIFY?
A. FATIGUE
B. RISK FOR INFECTION
C. ACTIVITY INTOLERANCE
D. IMPAIRED BOWEL ELIMINATION
RISK FOR INFECTION
A PATIENT HAVING ORIF AFTER AN OPEN FRACTURE IS AT RISK FOR PROBLEMS SUCH AS
WOUND INFECTION
AND OSTEOMYELITIS. AFTER ORIF, PATIENTS TYPICALLY ARE MOBILIZED STARTING THE
FIRST POSTOPERATIVE
DAY, SO RISKS OF IMMOBILITY SUCH AS FATIGUE, DECONDITIONING, AND CONSTIPATION
ARE NOT AS LIKELY.
THE SECOND DAY AFTER ADMISSION WITH A FRACTURED PELVIS, A PATIENT SUDDENLY
DEVELOPS
CONFUSION. WHICH ACTION WOULD THE NURSE TAKE FIRST?
A. TAKE THE BLOOD PRESSURE.
B. CHECK THE O2 SATURATION.
C. ASSESS PATIENT ORIENTATION.
D. OBSERVE FOR FACIAL ASYMMETRY.
CHECK THE O2 SATURATION.
THE PATIENT'S HISTORY AND CLINICAL MANIFESTATIONS SUGGEST A FAT EMBOLISM. THE
MOST IMPORTANT
ASSESSMENT IS OXYGENATION. THE OTHER ACTIONS ARE ALSO APPROPRIATE BUT WILL
BE DONE AFTER THE
NURSE ASSESSES O2 SATURATION.
