PT 3

40問 • 1年前

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A high school teacher 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?

"I will be able to use my fingers with more flexibility to grasp things."

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include?

Call the health care provider for numbness of the hand.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?

Assess the left axilla and change absorbent dressings as needed.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

The patient leans over to pull on shoes and socks.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first?

Administer prescribed PRN O2 at 4 L/min.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider?

The right arm appears shorter than the left.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first?

Wrap the ankle and apply an ice pack.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Reposition the patient every 1 to 2 hours.

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for

monitored anesthesia care.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first?

Assess leg pulses and sensation.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to

assess the pedal pulses.

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as

risk for infection related to disruption of skin integrity.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?

Check the O2 saturation.

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?

Slow capillary refill of the left foot

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should

assess the surgical site for hemorrhage.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?

Administer prescribed pain medication.

When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about

tingling in the right thumb and index finger.

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury?

Apply an immobilizer to the affected leg.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider?

Capillary refill to the fingers is prolonged.

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider?

Patient has been incontinent of urine and stool.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first?

Use a cervical collar to stabilize the spine.

After change-of-shift report, which patient should the nurse assess first?

Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?

Traction weights are resting on the floor

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?

Use a cloth-covered pillow to elevate the clients leg.

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture?

Pagets disease

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?

Assess the pedal pulses.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?

Administer oxygen via nasal cannula.

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?

A 74-year-old man who smokes and has a fractured pelvis

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?

Ensure that the weights remain freely hanging at all times.

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?

Immobilize the left arm.

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?

Meperidine (Demerol) 50 mg IV every 4 hours

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?

How would you describe the pain that you are feeling?

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first?

Raise the arm above the level of the heart.

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, The cast is loose enough to slide off. How should the nurse respond?

You need a new cast now that the swelling is decreased.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?

Hematuria

A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?

Skeletal traction will assist in realigning your fractured bone.

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?

Obtain a prescription to culture the drainage.

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first?

Intravenous calcitonin

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care?

Encourage range-of-motion exercises.

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?

Remove the medical alert bracelet from the fractured arm.

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