A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle acciden
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t. The patient has been placed in traction until his femur can be rodded in surgery. For what
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early complications should the nurse monitor this patient? Select all that apply.
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A) Systemic infection
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B) Complex regional pain syndrome
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C) Deep vein thrombosis
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D) Compartment syndrome
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E) Fat embolism - ans-C) Deep vein thrombosis
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D) Compartment syndrome
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E) Fat embolism
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A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction.
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What assessment findings are most consistent with this diagnosis?
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A) Hot skin with a capillary refill of 1 to 2 seconds
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B) Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
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C) Pain, diaphoresis, and erythema
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D) Jaundiced skin, weakness, and capillary refill of 3 seconds - ans-
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B) Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
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While assessing a patient who has had knee replacement surgery, the nurse notes that the
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patient has developed a hematoma at the surgical site. The affected leg has a decreased p
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edal pulse. What would be the priority nursing diagnosis for this patient?
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A) Risk for Infection
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B) Risk for Peripheral Neurovascular Dysfunction
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C) Unilateral Neglect
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D) Disturbed Kinesthetic Sensory Perception - ans-
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B) Risk for Peripheral Neurovascular Dysfunction
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A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms t
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hat the patient is able to perform plantar flexion. What conclusion can the nurse draw from t
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his finding? zx zx
A) The leg that was assessed is free from DVT.
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B) The patient's tibial nerve is functional.
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C) Circulation to the distal extremity is adequate.
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D) The patient does not have peripheral neurovascular dysfunction. - ans-
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B) The patient's tibial nerve is functional
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A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she
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has one prominent scapula that is accentuated by bending forward. The nurse should expe
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ct to read about what health problem in the patient's electronic health record.
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A) Lordosiszx
, B) Kyphosis
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C) Scoliosis
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D) Muscular dystrophy - ans-C) Scoliosis
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An older adult patient has come to the clinic for a regular check-
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up. The nurse's initial inspection reveals an increased thoracic curvature of the patient's spi
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ne. The nurse should document the presence of which of the following?
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A) Scoliosis
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B) Epiphyses
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C) Lordosis
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D) Kyphosis - ans-D) Kyphosis
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The results of a nurse's musculoskeletal examination show an increase in the lumbar curva
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ture of the spine. The nurse should recognize the presence of what health problem?
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A) Osteoporosis
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B) Kyphosis
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C) Lordosis
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D) Scoliosis - ans-C) Lordosis
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A patient has just had an arthroscopy performed to assess a knee injury. What nursing inter
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vention should the nurse implement following this procedure?
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A) Wrap the joint in a compression dressing.
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B) Perform passive range of motion exercises.
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C) Maintain the knee in flexion for up to 30 minutes.
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D) Apply heat to the knee. - ans-A) Wrap the joint in a compression dressing
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A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is gettin
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g ready to go home. The nurse should teach the patient to monitor closely for what post proc
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edure complication. zx
A) Feverzx
B) Crepitus
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C) Fasciculations
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D) Synovial fluid leakage - ans-A) Fever
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A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment revea
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ls that the child's muscles have greater-than-
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normal tone. The nurse should document the presence of which of the following?
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A) Tonuszx
B) Flaccidity
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C) Atonyzx
D) Spasticity - ans-D) Spasticity
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A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. T
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his patients prolonged immobility creates a risk for what complication?
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A) Muscle clonus
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B) Muscle atrophy
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