A nurse is assessing a client who is experiencing complications due to immobility. Which of the
following findings should the nurse expect? Select all that Apply
A. Contractors of the extremities
B. Polyuria
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers - Answers A. D. E.
A nurse is assessing a client who is 24 hour post operative following an open reduction and internal
fixation to repair a fracture of the femur. Which of the following assessment findings is an early
manifestation of acute compartment syndrome (ACS)
A. Dyspnea
B. red-brown petechia
C. Headache
D. Agitation - Answers A. Dyspnea - early manifestation of ACS that due to hypoxemia
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on
admission and again in 2 hours. Which of the following changes in assessment should indicate to the
nurse that the client could be developing a serious complication?
A. increased respiratory rate of 18 to 44/min
B. increased oral temperature of 36.6 C to 37.7 C
C. increased blood pressure from 112/68 to 120/72
D. Increased heart rate from 68 to 72 - Answers A. Increased respiratory rate of 18 to 44
A nurse is caring for a client who has returned from the surgical site following surgery for a fractured
mandible. The client had inter-maxillary fixation to repair and stabilize the fracture. Which of the
following actions is the priority for the nurse to take?
A. Prevent aspiration
B. Ensure adequate nutrition
C. Promote oral hygiene
D. Relieve the client's pain - Answers A. Prevent aspiration
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES)
following a fracture. Which of the following lab findings should the nurse expect?
A. decreased serum calcium levels
B. decreased level of serum lipids
C. decreased ESR
D. Increased platelet count - Answers A. decreased serum calcium levels
A nurse is caring for client who has impaired mobility. Which of the following support devices should
the nurse plan to use to prevent the client from developing plantar flexion contractors?
A. Trochanter roll
B. Sheepskin heel pad
C. Abduction pillow
D. Footboard - Answers C. Footboard- prevents foot drop
A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture.
Which of the following findings requires immediate notification to the provider?
A. Moderate level of pain
B. Dependent edema distal to the cast
C. Inability to flex toes of the casted foot
D. Ecchymosis of the distal foot - Answers C. Inability to flex toes of the casted foot
A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions
should the nurse implement to promote the client's mobility?
, A. Log rolling every 2 hours
B. Isometric exercises of both legs
C. Active range-of-motion exercises of the left leg
D. Passive range of motion to the right leg - Answers C. Active range-of-motion exercises of the left leg
A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur.
Which of the following interventions should the nurse include in the plan?
A. Instruct the client to flex and extend the ankle twice daily
B. Monitor the client's pedal pulses every hour
C. Remove the weights every four hours
D. Evaluate pressure points daily - Answers B. Monitor the client's pedal pulses every hour
A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that
the bone is splinted into several pieces around the shaft. The nurse should identify that the client has
which of the following types of fractures?
A. Impacted
B. Transverse
C. Comminuted
D. Oblique - Answers C. Comminuted
A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When
determining that the traction is appropriately assembled, the nurse should observe which of the
following?
A. Skin straps maintain the leg in an extended position
B. Weights are attached to a pin that is inserted in the femur
C. A padded sling is under the knee of the affected leg
D. The buttocks is elevated slightly off the bed - Answers D. The buttocks is elevated slightly off the
bed
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord
transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the
client's plan of care?
A. ability to achieve independent transfer from bed to wheelchair
B. Independent control of bowel and bladder function
C. Use of a wheelchair with a chin or mouth stick
D. Ability to self-feed with the use of adaptive equipment - Answers D. Ability to self-feed with the use
of adaptive equipment
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia.
Which of the following is the priority action for the nurse to take?
A. Perform a neuromuscular assessment
B. Explain the discharge instructions to the clients and parents
C. Provide reassurance to the clients and patients
D. Apply an ice pack to the casted leg - Answers A. Perform a neuromuscular assessment
A nurse is caring for a client who has a fracture of the forearm. The parent tells the nurse that the
provider said it was a green stick fracture and asks what that means. Which of the following
statements should the nurse make?
A. "The bone is broken on one side and bent on the other side"
B. "Fragments of bones have splintered into the surrounding area"
C. "The bone ends have been forced toward each other"
D. The sharp edge of the bone has broken through the skin" - Answers A. The bone is broken on one
side and bent on the other side
A nurse is caring for a client who is post operative following an open reduction internal fixation (ORIF)
of a femur fracture. Which of the following parameter should the nurse include in the evaluation of
the neurovascular status of the client's affect extremity? (Select all that Apply)