PT 4

45問 • 1年前

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A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?

Inability to initiate or maintain abduction of the affected arm at the shoulder

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?

Numbness in the extremity

After teaching a client with a fractured humerus, the nurse assesses the clients understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?

Roast beef with low-fat milk and a vitamin C supplement

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain?

Patient-controlled analgesia (PCA) pump with morphine

A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond?

Please come to the clinic today to have your arm checked by the provider.

A nurse cares for a client who had a long-leg cast applied last week. The client states, I cannot seem to catch my breath and I feel a bit light-headed. Which action should the nurse take next?

Administer oxygen to keep saturations greater than 92%.

A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, I dont want to live with only one leg. I should have died during the surgery. How should the nurse respond?

This is a big change for you. What support system do you have to help you cope?

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?

I can drive myself home after the procedure.

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection?

Schedule for pin care to be provided every shift.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.)

It leads to minimal blood loss., It allows for early ambulation., It promotes healing.

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)

Urinary output, Blood pressure, Skin color

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)

Administer additional opioids as prescribed., Elevate the extremity on pillows., Apply ice to the fracture site.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Elevate heels off the bed with a pillow., Ambulate the client on the first postoperative day., Re-position the client every 2 hours.

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)

Edema Increased capillary permeability, Unequal pulses Increased production of lactic acid, Cyanosis Anaerobic metabolism

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this clients teaching? (Select all that apply.)

Frequently assess the ergonomics of the equipment being used., Take breaks to stretch fingers and wrists during working hours., Adjust chair height to allow for good posture.

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this clients teaching? (Select all that apply.)

The device has been custom made specifically for you., Make sure that you wear the correct liners with your prosthetic., I have scheduled a follow-up appointment for you.

Immobility reduces muscle contractions and can produce muscle _____

atrophy

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates additional patient teaching is needed?

"I did not have this bone cancer until my leg broke a week ago."

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?

Temperature 101.4° F (38.6° C)

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to

check the chart for preoperative assessment data.

Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Log roll the patient from side to side every 2 hours.

A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?

Patient who has not voided 10 hours after a laminectomy

Which fracture is a most commonly seen in children?

Greenstick

The nurse is at the bedside completing an assessment on a patient who has a hip fracture. Which signs and symptoms are indicative of fat embolism?

Measles-like rash over the neck, upper arms, chest, or abdomen

A patient has a complete fracture of the right humerus in the middle part of the bone. Which treatment would the nurse expect the health care provider to use to correct the fracture?

Closed reduction

Which type of gait is appropriate for use with a walker?

Modified swing-to gait

grieving early before death

anticapatory grieve

Which factor is considered a long-term complication of a fracture?

Avascular necrosis

A patient has sustained an open fracture and is admitted for a closed reduction. The nurse assigned to this patient is at the bedside assisting with data collection. Which statement by the patient alerts the nurse that the patient may be experiencing compartment syndrome?

I have extreme pain that the pain medication is not relieving.

Which long-term complication of a fracture is treated by physical therapy, nerve blocks, or muscle relaxants?

Complex regional pain syndrome

The health care provider has applied a long arm cast made of plaster of Paris to treat an ulnar fracture. The nurse is teaching the patient about cast care. Which statement made by the patient indicates a need for further teaching?

"My cast will be drying for 10 to 15 minutes."

During which stage of bone healing does the permanent bone callus begin to form and allow the broken bone pieces to begin to knit?

Ossification

Which nursing interventions are appropriate for the patient recovering from a total hip surgery? (Select all that apply.)

Perform exercises for physical therapy., Limit weight bearing on the affected side initially., Walk the patient with use of a walker as tolerated., Use comfort measures such as repositioning and back massage.

A patient recently had a below-the-knee amputation. Which assessment finding of the skin flap would require immediate intervention by the nurse?

Skin flap is pale and cool to touch

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Ensure the weight for the traction is hanging freely.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first?

Check the patient's O2 saturation using pulse oximetry.

A nurse is caring for multiple patients with above-the-knee amputations. Which patient would the nurse assess first?

A patient who complains of phantom limb pain.

A patient with diabetes is hospitalized for a below-the-knee amputation. Which specific assessment would be made because of the patient's history of diabetes?

Separation of wound edges (dehiscence)

A patient is scheduled for a below-the-knee amputation because of gangrene. Which type of amputation should the nurse anticipate caring for postoperatively?

Open amputation

A patient required an above-the-knee amputation for a crush injury to the lower left leg. Twenty-four hours after surgery, the patient is reporting that their left foot is itching and asks why this is happening. What would be the best response by the nurse?

"You are experiencing phantom limb sensation, which is a completely normal response after amputation.

The nurse is assessing the compression dressing for a patient 4 hours after a below-the-knee amputation for bleeding. A small amount of drainage is noted on the dressing. Which method is used to correctly document the drainage?

Circling the drainage with a pen and then documenting it in the patient's chart

A 57-year-oldpatient is undergoing a complete physical examination before undergoing an amputation of the right leg. Which reason is most likely the reason for this type of amputation?

Vascular disease

Which conditions or situations may lead to an amputation? (Select all that apply.)

Tumors, Trauma, Disease, Congenital anomalies

Which early signs of hemorrhage should be assessed during the immediate postoperative period in a patient with an amputation? (Select all that apply.)

Restlessness, Increasing pulse rate, Increasing respiratory rate

Which postoperative teaching is important at discharge for a patient who has undergone successful replantation of an upper extremity? (Select all that apply.)

Avoid tight clothing around the affected extremity, Report changes in color or warmth of replanted limb

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