RNSG 1443 Exam 4
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RNSG 1443
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,The nurse is preparing a client who sustained a hip fracture for discharge. The nurse should teach
the client to avoid which of the following groups of activities to prevent dislocation of the hip?
A. crossing legs, bending at hips, and sitting on low toilet seats
B. taking leisurely walks, low chair seats, and bending at hips
C. using reachers for applying shoes and socks, and sitting in chairs with arms
D. all exercises, bedrest, and using raised toilet seats - ANS- A.crossing legs, bending at hips, and
sitting on low toilet seats
A client in traction slides down in the bed so that the feet touch the foot of the bed. What should the
nurse do to ensure that the pull of traction remains uninterrupted?
A. release the weights, pull the client up in bed, and then reapply weights
B. ask the physician for a change in the amount of weight ordered
C. move the client up in bed without releasing the pull of traction on the extremity
D. elevate the client's feet on a pillow - ANS- C.move the client up in bed without releasing the pull
of traction on the extremity
The nurse is assessing a casted extremity of a patient. Which sign is indicative of infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity - ANS- C. Presence of a "hot spot" on the cast
Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast
or the presence of "hot spots," which are areas of the cast that are warmer than others. The health
care provider should be notified if any of these occur.
Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished
distal pulse, and edema.
A patient being measured for crutches asks the nurse why the crutches cannot rest up underneath
the arm for extra support. The nurse responds that knowing that which would most likely result from
this improper measurement?
A. A fall and further injury
B. Injury to the brachial plexus nerves
, C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the patient ambulates - ANS- B. Injury to the brachial plexus
nerves
Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures
that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could
result in injury to the nerves of the brachial plexus.
Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from
resting the axilla directly on the crutches.
The nurse has conducted teaching with a patient in an arm cast about the s/s of compartment
syndrome. The nurse determines that the client understands the information if the client states that
he or she should report which of the early symptom of compartment syndrome?
A. Cold, bluish-colored fingers
B. Numbness and tingling of the fingers
C. Pain that increases when the arm is dependent
D. Pain that is out of proportion to the severity of the fracture - ANS- B. Numbness and tingling of
the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the
fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation,
and pallor and coolness to the distal limb.
Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other
symptoms associated with the pain, is not an early manifestation.
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data
would the nurse evaluate as the most favorable indication of resolution of the fat embolus?
a. clear mentation
b. minimal dyspnea
c. oxygen saturation of 85%
d. arterial oxygen level of 78 mmHg - ANS- a. clear mentation
The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the
increased risk for