Med Surg Final Exam Questions & Answers | Medical-
Surgical Nursing Study Guide| Highlighting Correct and
Incorrect Answers|100% Guarantee Pass | Latest
Exam and Brand new Version!!!
A nurse is caring for a client who has a fractured hip and was placed
in Buck's traction 4 hr ago. Which of the following actions should the
nurse take?
a. Inspect the client's skin underneath the boot every 12 hr
b. Encourage the client to perform dorsiflexion of the affected
extremity every 2 hr
c. Remove the weights from the traction while repositioning the
client in bed
d. Loosen the ropes if the client reports muscle spasms in the
affected extremity
ANS: B. Encourage the client to perform dorsiflexion of the affected
extremity every 2 hr ---The nurse should encourage the client to
perform dorsiflexion of the affected extremity every 2 hours to
assess if the client is experiencing nerve damage. Weakness of
dorsiflexion can indicate peroneal nerve damage. If this occurs, the
nurse should notify the provider immediately.
Incorrect Answers:
A. The nurse should inspect the client's skin underneath the boot for
irritation, increased swelling, and skin breakdown every 8 hours.
C. The weights should never be removed without a prescription from
the provider. The purpose of the weights is to decrease muscle
spasms as a result of the hip fracture.
,D. The ropes of the traction should never be loosened. This can
affect the traction and increase the client's muscle spasms.
A nurse is caring for a client who has a fractured right hip. Which of
the following types of traction should the nurse expect the client to
have prior to hip arthroplasty surgery?
a. Balanced skeletal traction
b. Pelvic belt
c. Pelvic sling
d. Buck's traction
ANS: D. Buck's traction---Buck's traction is used prior to hip
arthroplasty to maintain alignment and prevent muscle spasms prior
to surgery.
Incorrect Answers:
A. Balanced skeletal traction is used to stabilize fractures of the
femur or pelvis, not the hip. Skeletal traction involves the surgical
insertion of pins, tongs, wires, or screws; this is sometimes used to
stabilize long bone and vertebral fractures. B. A pelvic belt is used to
treat back pain and does not provide traction prior to hip
arthroplasty.
C. A pelvic sling is used to stabilize pelvic fractures, not hip
fractures.
A nurse is caring for a client with a hip fracture who has Buck's
extension traction in place. Which of the following pieces of
information should the nurse give the client about this type of
traction? (Select all that apply.)
a. "You'll have considerably less pain with the traction in place."
b. "You'll have the traction in place for a week or so."
c. "The traction will help decrease muscle spasms."
d. "The weights act as a pulling force to keep your leg and hip still."
,e. "We have to make sure the weights are just barely touching the
floor."
ANS:
A. "You'll have considerably less pain with the traction in place."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
Pain is usually more severe without the traction. Buck's extension
traction uses weights to help decrease muscle spasms. Typically,
2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg
preoperatively.
A nurse is caring for a client who is scheduled to undergo surgery to
repair an open hip fracture. In which of the following positions
should the nurse plan to place the client postoperatively?
a. With the leg on the affected side adducted
b. With the hip externally rotated on the affected side
c. With the leg on the affected side abducted
d. With the hip flexed to 90° on the affected side
ANS: C. With the leg on the affected side abducted---The nurse
should plan to place the client with the leg abducted on the affected
side postoperatively. Adduction or external rotation of the leg will
cause the hip to dislocate.
A nurse is assessing a client who has a fractured left femur and is in
skeletal traction. Which of the following findings should the nurse
report to the provider?
a. Ecchymosis of the thigh
b. Serous drainage at the pin site
c. Chest petechiae
d. Muscle spasms in the left leg
ANS: C. Chest petechiae--- The nurse should identify chest petechiae
as an indication of fat embolism syndrome. Clients who have
, fractures of the long bones such as the femur are at increased risk of
fat emboli. Fat emboli typically occur 12 to 48 hours after the injury
when fat droplets from the marrow enter into the systemic
circulation and are deposited in the lungs. The nurse should
immediately notify the provider because the client could progress to
acute respiratory failure.
A nurse is preparing to care for a client who is in balanced skeletal
traction to stabilize a femur fracture. Which of the following actions
should the nurse include in the client's plan of care?
a. Offering the client a diet high in fluid and fiber
b. Encouraging active range of motion of the affected leg
c. Removing the weights prior to repositioning the client
d. Inspecting pin sites every 24 hr for drainage
ANS: A. Offering the client a diet high in fluid and fiber---- A client
who is immobile is at risk of constipation. The nurse should
encourage a diet high in fluid and fiber to promote gastrointestinal
function.
Incorrect Answers:
B. Active range of motion of the unaffected limbs is encouraged to
prevent muscle wasting; however, active range of motion of a limb in
traction is not feasible, as the traction apparatus limits mobility.
C. Once the weights are in place, the nurse should not remove them.
D. The nurse should plan to inspect the client's pin sites at least
every 8 to 12 hours due to the risk of infection.
A nurse is caring for a client who is in skeletal traction following a
femur fracture. On entering, the nurse finds that the client has slid
toward the foot of the bed, and the traction weight is resting on the
floor. Which of the following actions should the nurse take?
a. Remove the weight temporarily to reposition the client to the
correct alignment in bed
Surgical Nursing Study Guide| Highlighting Correct and
Incorrect Answers|100% Guarantee Pass | Latest
Exam and Brand new Version!!!
A nurse is caring for a client who has a fractured hip and was placed
in Buck's traction 4 hr ago. Which of the following actions should the
nurse take?
a. Inspect the client's skin underneath the boot every 12 hr
b. Encourage the client to perform dorsiflexion of the affected
extremity every 2 hr
c. Remove the weights from the traction while repositioning the
client in bed
d. Loosen the ropes if the client reports muscle spasms in the
affected extremity
ANS: B. Encourage the client to perform dorsiflexion of the affected
extremity every 2 hr ---The nurse should encourage the client to
perform dorsiflexion of the affected extremity every 2 hours to
assess if the client is experiencing nerve damage. Weakness of
dorsiflexion can indicate peroneal nerve damage. If this occurs, the
nurse should notify the provider immediately.
Incorrect Answers:
A. The nurse should inspect the client's skin underneath the boot for
irritation, increased swelling, and skin breakdown every 8 hours.
C. The weights should never be removed without a prescription from
the provider. The purpose of the weights is to decrease muscle
spasms as a result of the hip fracture.
,D. The ropes of the traction should never be loosened. This can
affect the traction and increase the client's muscle spasms.
A nurse is caring for a client who has a fractured right hip. Which of
the following types of traction should the nurse expect the client to
have prior to hip arthroplasty surgery?
a. Balanced skeletal traction
b. Pelvic belt
c. Pelvic sling
d. Buck's traction
ANS: D. Buck's traction---Buck's traction is used prior to hip
arthroplasty to maintain alignment and prevent muscle spasms prior
to surgery.
Incorrect Answers:
A. Balanced skeletal traction is used to stabilize fractures of the
femur or pelvis, not the hip. Skeletal traction involves the surgical
insertion of pins, tongs, wires, or screws; this is sometimes used to
stabilize long bone and vertebral fractures. B. A pelvic belt is used to
treat back pain and does not provide traction prior to hip
arthroplasty.
C. A pelvic sling is used to stabilize pelvic fractures, not hip
fractures.
A nurse is caring for a client with a hip fracture who has Buck's
extension traction in place. Which of the following pieces of
information should the nurse give the client about this type of
traction? (Select all that apply.)
a. "You'll have considerably less pain with the traction in place."
b. "You'll have the traction in place for a week or so."
c. "The traction will help decrease muscle spasms."
d. "The weights act as a pulling force to keep your leg and hip still."
,e. "We have to make sure the weights are just barely touching the
floor."
ANS:
A. "You'll have considerably less pain with the traction in place."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
Pain is usually more severe without the traction. Buck's extension
traction uses weights to help decrease muscle spasms. Typically,
2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg
preoperatively.
A nurse is caring for a client who is scheduled to undergo surgery to
repair an open hip fracture. In which of the following positions
should the nurse plan to place the client postoperatively?
a. With the leg on the affected side adducted
b. With the hip externally rotated on the affected side
c. With the leg on the affected side abducted
d. With the hip flexed to 90° on the affected side
ANS: C. With the leg on the affected side abducted---The nurse
should plan to place the client with the leg abducted on the affected
side postoperatively. Adduction or external rotation of the leg will
cause the hip to dislocate.
A nurse is assessing a client who has a fractured left femur and is in
skeletal traction. Which of the following findings should the nurse
report to the provider?
a. Ecchymosis of the thigh
b. Serous drainage at the pin site
c. Chest petechiae
d. Muscle spasms in the left leg
ANS: C. Chest petechiae--- The nurse should identify chest petechiae
as an indication of fat embolism syndrome. Clients who have
, fractures of the long bones such as the femur are at increased risk of
fat emboli. Fat emboli typically occur 12 to 48 hours after the injury
when fat droplets from the marrow enter into the systemic
circulation and are deposited in the lungs. The nurse should
immediately notify the provider because the client could progress to
acute respiratory failure.
A nurse is preparing to care for a client who is in balanced skeletal
traction to stabilize a femur fracture. Which of the following actions
should the nurse include in the client's plan of care?
a. Offering the client a diet high in fluid and fiber
b. Encouraging active range of motion of the affected leg
c. Removing the weights prior to repositioning the client
d. Inspecting pin sites every 24 hr for drainage
ANS: A. Offering the client a diet high in fluid and fiber---- A client
who is immobile is at risk of constipation. The nurse should
encourage a diet high in fluid and fiber to promote gastrointestinal
function.
Incorrect Answers:
B. Active range of motion of the unaffected limbs is encouraged to
prevent muscle wasting; however, active range of motion of a limb in
traction is not feasible, as the traction apparatus limits mobility.
C. Once the weights are in place, the nurse should not remove them.
D. The nurse should plan to inspect the client's pin sites at least
every 8 to 12 hours due to the risk of infection.
A nurse is caring for a client who is in skeletal traction following a
femur fracture. On entering, the nurse finds that the client has slid
toward the foot of the bed, and the traction weight is resting on the
floor. Which of the following actions should the nurse take?
a. Remove the weight temporarily to reposition the client to the
correct alignment in bed
