Lewis Chapter 67: Musculoskeletal Trauma and Orthopedic Surgery

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.

c. Use pillows to elevate the ankle above the heart.

d. Gently move the ankle through the range of motion.

Use pillows to elevate the ankle above the heart.

Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching?

a. "You will not be able to serve a tennis ball again."

b. "You will begin exercises with a physical therapist tomorrow."

c. "Keep the shoulder immobilizer on for the first 6 months to minimize pain."

d. "The surgeon will use the drop arm test to determine the success of surgery."

"You will begin exercises with a physical therapist tomorrow."

Physical therapy exercises to prevent "frozen shoulder" begin on the first postoperative day after a rotator cuff repair. A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for months would lead to loss of range of motion. The drop arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to 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 scissors."

b. "I should avoid moving my fingers until the cast is removed."

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 cotton-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 observation by the nurse indicates the patient can safely ambulate independently?

a. The patient moves the right crutch with the right leg and then the left crutch with the left leg.

b. The patient advances the left leg and both crutches together and then advances the right leg.

c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.

d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

The patient advances the left leg and both crutches together and then advances the right leg.

Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. If the 2- or 4-point gait is to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage.

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV 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.

Clinical Manifestations of Compartment syndrome pg. 1655

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. Traction weights are usually 5 to 10 lbs- sometimes used for hip, knee, or femur fracture. 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. pg 1647

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 sites daily."

b. "Remain on bed rest until bone healing is complete."

c. "Remove the external fixator for your daily shower."

d. "Take prophylactic antibiotics until the fixator is removed."

"Check and clean the pin insertion sites daily."

Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action would the nurse take?

a. Check the patient's prescribed weight-bearing status.

b. Use a mechanical lift to transfer the patient to the chair.

c. Wean down the pain medication before getting the patient up.

d. Have the assistive personnel (AP) transfer the patient to a chair.

Check the patient's prescribed weight-bearing status.

The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given but not decreased because the movement is likely to increase the patient's pain. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

Which information would the nurse include in discharge teaching for a patient who has had a 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.

Discharge teaching should include oral care, diet, how to handle secretions, how and when to use wire cutters or scissors, and when to notify the HCP. pg 1664

After the HCP recommends amputation for a patient who has non-healing 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, but 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 options for treatment."

d. "If you do not want an amputation, you do not have to have it."

"Tell me what you know about your options 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 times a day."

b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

c. "I should change the limb sock when it becomes soiled or each week."

d. "I should use lotion on the stump to prevent skin drying and cracking."

“I should lie flat on my abdomen for 30 minutes 3 or 4 times a day.”

The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture.

Table 67.15 pg 1667

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed?

a. "I should not cross my legs while sitting."

b. "I will use an elevated toilet seat."

c. "I will have someone else put on my shoes and socks."

d. "I can sleep in any position that is comfortable for me."

"I can sleep in any position that is comfortable for me."

The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

Which action would the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

a. Avoid extension of the right knee beyond 120 degrees.

b. Use a compression bandage to keep the right knee flexed.

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.

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 will correct the deformities in my fingers."

b. "I will not have to do as many hand exercises after the surgery."

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

d. "My fingers will appear more normal in size and shape after this surgery."

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

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

The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient can do active ROM on the uninjured side.

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

a. Using crutches with a swing-to gait

b. Sitting upright on the edge of the bed

c. Leaning over to pull on shoes and socks

d. Bending over the sink while brushing teeth

Leaning over to pull on shoes and socks

Leaning over to reach the feet would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions do not require any immediate action by the nurse to protect the patient.

After being hospitalized for 2 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 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

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

Repositioning of orthopedic patients is within the scope of practice of AP after they have been trained and evaluated in this skill. The other actions should be done by licensed nursing staff members.

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. Which information would the nurse plan to teach the patient first?

a. Use of a knee immobilizer

b. Monitored anesthesia care

c. Physical activity restrictions

d. Performance of gentle knee flexion

Monitored anesthesia care

The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned.

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

a. Elevate the leg on 2 pillows.

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.

Fat embolism syndrome (FES) is characterized by fat globules entering the circulatory system from fractures. They collect in areas with abundant blood vessels, especially the brain and lungs. FES is most often associated with long bones, ribs, tibia, and pelvis.

Clinical manifestation of FES:

Happens within 24 to 48 hours of injury. FES in the lungs cause hemorrhagic interstitial pneumonitis with signs and symptoms of acute respiratory distress. These include chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia. These symptoms are caused by poor O2 exchange. Changes in mental status due to hypoxemia are common. pg 1656

The nurse admits a patient to the emergency department with a left femur fracture. Which assessment finding is most important to report to the health care provider?

a. Bruising of the left thigh

b. Reports of severe thigh pain

c. Slow capillary refill of the left foot

d. Outward pointing toes on the left foot

Slow capillary refill of the left foot

Prolonged capillary refill may indicate complications such as compartment syndrome. Bruising, pain, and rotation are typical with a femur fracture.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. Which action would the nurse take when the patient arrives on the orthopedic unit after surgery?

a. Assess the surgical site for hemorrhage.

b. Remove the prosthesis and wrap the site.

c. Place the patient in a side-lying position.

d. Keep the residual limb elevated on a pillow.

Assess the surgical site for hemorrhage.

The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg should not be elevated on a pillow or flexed in a side lying position.

The nurse is preparing to assist a patient with ambulation 2 days after total hip arthroplasty. Which action is most important for the nurse to take?

a. Observe output from the surgical drain.

b. Administer prescribed pain medication.

c. Instruct the patient about benefits of early ambulation.

d. Change the dressing and document the wound appearance.

Administer prescribed pain medication.

The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A patient has possible carpal tunnel syndrome. Which symptom would the nurse expect with a positive Tinel's sign?

a. Weakness in the little finger

b. Burning in the elbow and forearm

c. Tremor when gripping with the hand

d. Tingling in the thumb and index finger

d. Tingling in the thumb and index finger

Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

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

a. Encourage bed rest for 24 to 48 hours.

b. Apply an immobilizer to the affected leg.

c. Avoid palpation or movement of the knee.

d. Administer intravenous opioids for pain management

Apply an immobilizer to the affected leg.

A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are recommended for pain management.

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

a. The patient reports severe pain.

b. Swelling is noted around the wrist.

c. Capillary refill to the fingers is slow.

d. The wrist has a deformed appearance.

Capillary refill to the fingers is slow.

Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

Which information about a patient with a lumbar vertebral compression fracture would the nurse immediately report to the health care provider?

a. Patient declines to be turned due to back pain.

b. Patient has been incontinent of urine and stool.

c. Patient reports lumbar area tenderness to palpation.

d. Patient frequently uses oral corticosteroids to treat asthma.

Patient has been incontinent of urine and stool

Changes in bowel or bladder function indicate possible spinal cord compression and would be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.

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

a. Assess for nasal bleeding and pain.

b. Apply ice to the face to reduce swelling.

c. Use a cervical collar to stabilize the spine.

d. Check the patient's alertness and orientation

Use a cervical collar to stabilize the spine.

Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

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

a. Patient with a repaired mandibular fracture who is reporting facial pain

b. Patient with repaired right femoral shaft fracture who reports tightness in the calf

c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity

d. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated

Patient with repaired right femoral shaft fracture who reports tightness in the calf

Calf swelling after a femoral shaft fracture suggests possible DVT or compartment syndrome that could lead to limb loss. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced assistive personnel (AP)?

a. Remove and reapply traction periodically.

b. Ensure the weight for the traction is hanging freely.

c. Monitor the skin under the traction boot for redness.

d. Check for intact sensation and movement in the affected leg.

Ensure the weight for the traction is hanging freely.

AP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN).

HPI: 23 y/o presents to ED with RLE injury

Assessment: Reports severe RLE pain and SOB; the bone is protruding from the leg.

Diagnostic Exams: WBC 9400, Hgb 11.6; RLE XR confirms R tibial FX.

Which action would the nurse take first?

a. Administer the prescribed morphine 4 mg IV

b. Contact the OR to schedule surgery

c. Check the patient's O2 saturation using pulse oximetry

d. Ask the patient the date of his last tetanus immunization

Check the patient's O2 saturation using pulse oximetry.

Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring?

A Paresthesia

B Pitting edema

C Poor venous return

D Compartment syndrome

Compartment syndrome

The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. Obtain x-rays.

b. Check pedal pulses.

c. Assess lung sounds.

d. Take blood pressure.

e. Apply splint to the leg.

f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F

The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time?

A. 9:30 PM

B. 10:00 AM

C. 11:00 AM

D. 1:00 PM

11:00 AM

A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.

A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information?

A. Two additional follow-up scans will be required.

B. There will be only mild pain associated with the procedure.

C. The procedure takes approximately 15 to 30 minutes to complete.

D. The patient will be asked to drink increased fluids after the procedure.

The patient will be asked to drink increased fluids after the procedure.

Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus?

A. 22-year-old female with gonorrhea who is an IV drug user

B. 48-year-old male with muscular dystrophy and acute bronchitis

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer

D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer

Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement?

A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus."

B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing."

D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

"The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing."

After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic illeus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient?

A. Nausea and vomiting

B. Localized pain and warmth

C. Paresthesia in the affected extremity

D. Generalized bone pain throughout the leg

Localized pain and warmth

Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate?

A. "IV antibiotics are usually required for several weeks."

B. "Oral antibiotics are often required for several months."

C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present."

D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

"IV antibiotics are usually required for several weeks."

The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention?

A. Ambulate the patient to the bathroom every 2 hours.

B. Ask the patient about preferred activities to relieve boredom.

C. Allow the patient to dangle legs at the bedside every 2 to 4 hours.

D. Perform frequent position changes and range-of-motion exercises.

Perform frequent position changes and ROM exercises.

The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing ROM exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers Select all that apply.

a."The beads are used to directly deliver antibiotics to the site of the infection."

b."There are no effective oral or IV antibiotics to treat most cases of bone infection."

c."This is the safest method of delivering long-term antibiotic therapy for a bone infection."

d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections."

e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

"The beads are used to directly deliver antibiotics to the site of the infection."

"The beads are an adjunct to debridement and oral and IV antibiotics for deep infections."

Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.