EXAM 4

The nurse suspects an ankle sprain when a patient at the urgent care center relates

• a. being hit by another soccer player during a game.

• b. having ankle pain after sprinting around the track.

• c. dropping a 10-lb weight on his lower leg at the health club.

• d. twisting his ankle while running bases during a baseball game.

Answer explanation

A sprain is an injury to the ligamentous structures surrounding a joint, and a wrenching or twisting motion usually causes it. Most sprains occur in the ankle and knee join

An indication of a neurovascular problem noted during assessment of the patient with a fracture is

• a. exaggeration of strength with movement.

• b. increased redness and heat below the injury.

• c. decreased sensation distal to the fracture site.

• d. purulent drainage at the site of an open fracture.

Answer explanation

Rationale: Musculoskeletal injuries have the potential for causing changes in the neurovascular status of an injured extremity. In cases of musculoskeletal trauma, application of a cast or constrictive dressing, poor positioning, and the physiologic responses to the traumatic injury can cause nerve or vascular damage, usually distal to the injury. The neurovascular assessment consists of a peripheral evaluation (i.e., color, temperature, capillary refill, peripheral pulses, and edema) and a peripheral neurologic evaluation (i.e., sensation, motor function, and pain).

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences

• a. increasing edema of the limb.

• b. muscle spasms of the lower arm.

• c. rebounding pulse at the fracture site.

• d. pain when passively extending the fingers.

Answer explanation

Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply)

• a. fuse the joint.

• b. replace the joint.

• c. prevent further damage.

• d. improve or maintain ROM.

Answer explanation

Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant relief of pain and improvement of function for a patient with osteoarthritis (OA).

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of what in the preoperative period?

• a. Pain

• b. Left knee stiffness

• c. Left knee infection

• d. Left knee instability

Answer explanation

It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability may be present with osteoarthritis.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order?

• a. Administer a dose of prescribed analgesic before completing the order.

• b. Ask the physical therapist for a walker to limit weight bearing while getting out of bed.

• c. Keep the continuous passive motion machine in place while lifting the patient from bed to chair.

• d. Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

Answer explanation

The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to

• a. avoid crossing his legs.

• b. use a toilet elevator on toilet seat.

• c. notify future caregivers about the prosthesis.

• d. maintain hip in adduction and internal rotation.

Answer explanation

The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time?

• a. Auscultate for adventitious breath sounds.

• b. Obtain the patient's blood pressure and temperature.

• c. Remind the patient about harmful effects of smoking.

• d. Ask the health care provider about prescribing a nicotine patch.

Answer explanation

The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take?

• a. Provide an explanation of the planned surgical procedure.

• b. Notify the surgeon that the informed consent process is not complete.

• c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.

• d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

Answer explanation

The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy?

• a. Care for the surgical incision

• b. Medications used during surgery

• c. Deep breathing and coughing techniques

• d. Oral antibiotic therapy after discharge home

Answer explanation

Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.