Final Exam - Med Surg
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1. A nurse is caring for a client who B. Encourage the client to perform dorsiflexion of the
has a fractured hip and was placed affected extremity every 2 hr ---The nurse should en-
in Buck's traction 4 hr ago. Which courage the client to perform dorsiflexion of the affect-
of the following actions should the ed extremity every 2 hours to assess if the client is
nurse take? experiencing nerve damage. Weakness of dorsiflexion
can indicate peroneal nerve damage. If this occurs, the
a. Inspect the client's skin under- nurse should notify the provider immediately.
neath the boot every 12 hr
b. Encourage the client to perform Incorrect Answers:
dorsiflexion of the affected extrem- A. The nurse should inspect the client's skin under-
ity every 2 hr neath the boot for irritation, increased swelling, and
c. Remove the weights from the skin breakdown every 8 hours.
traction while repositioning the C. The weights should never be removed without a pre-
client in bed scription from the provider. The purpose of the weights
d. Loosen the ropes if the client re- is to decrease muscle spasms as a result of the hip
ports muscle spasms in the affect- fracture.
ed extremity D. The ropes of the traction should never be loosened.
This can affect the traction and increase the client's
muscle spasms.
2. A nurse is caring for a client who D. Buck's traction---Buck's traction is used prior to hip
has a fractured right hip. Which arthroplasty to maintain alignment and prevent muscle
of the following types of traction spasms prior to surgery.
should the nurse expect the client
to have prior to hip arthroplasty Incorrect Answers:
surgery? A. Balanced skeletal traction is used to stabilize fractures
of the femur or pelvis, not the hip. Skeletal traction
a. Balanced skeletal traction involves the surgical insertion of pins, tongs, wires, or
b. Pelvic belt screws; this is sometimes used to stabilize long bone
c. Pelvic sling and vertebral fractures. B. A pelvic belt is used to treat
d. Buck's traction back pain and does not provide traction prior to hip
arthroplasty.
, Final Exam - Med Surg
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C. A pelvic sling is used to stabilize pelvic fractures, not
hip fractures.
3. A nurse is caring for a client with A. "You'll have considerably less pain with the traction in
a hip fracture who has Buck's ex- place."
tension traction in place. Which of C. "The traction will help decrease muscle spasms."
the following pieces of information D. "The weights act as a pulling force to keep your leg
should the nurse give the client and hip still."
about this type of traction? (Select Pain is usually more severe without the traction. Buck's
all that apply.) extension traction uses weights to help decrease muscle
spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps
a. "You'll have considerably less stabilize the hip and leg preoperatively.
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."
4. A nurse is caring for a client who C. With the leg on the affected side abducted---The
is scheduled to undergo surgery nurse should plan to place the client with the leg ab-
to repair an open hip fracture. In ducted on the affected side postoperatively. Adduction
which of the following positions or external rotation of the leg will cause the hip to
should the nurse plan to place the dislocate.
client postoperatively?
a. With the leg on the affected side
adducted
, Final Exam - Med Surg
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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
5. A nurse is assessing a client who C. Chest petechiae--- The nurse should identify chest
has a fractured left femur and is in petechiae as an indication of fat embolism syndrome.
skeletal traction. Which of the fol- Clients who have fractures of the long bones such as
lowing findings should the nurse the femur are at increased risk of fat emboli. Fat emboli
report to the provider? typically occur 12 to 48 hours after the injury when fat
droplets from the marrow enter into the systemic circu-
a. Ecchymosis of the thigh lation and are deposited in the lungs. The nurse should
b. Serous drainage at the pin site immediately notify the provider because the client could
c. Chest petechiae progress to acute respiratory failure.
d. Muscle spasms in the left leg
6. A nurse is preparing to care for a A. Offering the client a diet high in fluid and fiber----
client who is in balanced skeletal A client who is immobile is at risk of constipation. The
traction to stabilize a femur frac- nurse should encourage a diet high in fluid and fiber to
ture. Which of the following actions promote gastrointestinal function.
should the nurse include in the
client's plan of care? Incorrect Answers:
B. Active range of motion of the unaffected limbs is
a. Offering the client a diet high in encouraged to prevent muscle wasting; however, active
fluid and fiber range of motion of a limb in traction is not feasible, as
b. Encouraging active range of mo- the traction apparatus limits mobility.
tion of the affected leg C. Once the weights are in place, the nurse should not
c. Removing the weights prior to remove them.
repositioning the client 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.
, Final Exam - Med Surg
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d. Inspecting pin sites every 24 hr
for drainage
7. A nurse is caring for a client who B. Have the client use a trapeze to pull himself up while
is in skeletal traction following a ensuring the weight hangs freely---The nurse should
femur fracture. On entering, the ensure that traction weight is hanging freely. The client
nurse finds that the client has slid can use an overhead trapeze bar to move up in bed,
toward the foot of the bed, and or the nurse can assist the client while making sure to
the traction weight is resting on the maintain proper alignment of the extremity.
floor. Which of the following actions
should the nurse take?
a. Remove the weight temporarily
to reposition the client to the cor-
rect alignment in bed
b. Have the client use a trapeze to
pull himself up while ensuring the
weight hangs freely
c. Lift the rope off the pulley while
the client rocks back and forth to
reposition himself
d. Lift the weight manually while
another staff member moves the
client up in bed
8. A nurse delegates the collection D. Right communication--- The situation could have
of a client's temperature to an as- been avoided if the right communication was given by
sistive personnel (AP). The nurse the nurse to the AP. The right communication entails
notes in the documentation that providing clear, concise instructions regarding the task,
the AP obtained the client's ax- including the objective, limits, and expectations.
illary temperature; however, the
nurse wanted an oral temperature.
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1. A nurse is caring for a client who B. Encourage the client to perform dorsiflexion of the
has a fractured hip and was placed affected extremity every 2 hr ---The nurse should en-
in Buck's traction 4 hr ago. Which courage the client to perform dorsiflexion of the affect-
of the following actions should the ed extremity every 2 hours to assess if the client is
nurse take? experiencing nerve damage. Weakness of dorsiflexion
can indicate peroneal nerve damage. If this occurs, the
a. Inspect the client's skin under- nurse should notify the provider immediately.
neath the boot every 12 hr
b. Encourage the client to perform Incorrect Answers:
dorsiflexion of the affected extrem- A. The nurse should inspect the client's skin under-
ity every 2 hr neath the boot for irritation, increased swelling, and
c. Remove the weights from the skin breakdown every 8 hours.
traction while repositioning the C. The weights should never be removed without a pre-
client in bed scription from the provider. The purpose of the weights
d. Loosen the ropes if the client re- is to decrease muscle spasms as a result of the hip
ports muscle spasms in the affect- fracture.
ed extremity D. The ropes of the traction should never be loosened.
This can affect the traction and increase the client's
muscle spasms.
2. A nurse is caring for a client who D. Buck's traction---Buck's traction is used prior to hip
has a fractured right hip. Which arthroplasty to maintain alignment and prevent muscle
of the following types of traction spasms prior to surgery.
should the nurse expect the client
to have prior to hip arthroplasty Incorrect Answers:
surgery? A. Balanced skeletal traction is used to stabilize fractures
of the femur or pelvis, not the hip. Skeletal traction
a. Balanced skeletal traction involves the surgical insertion of pins, tongs, wires, or
b. Pelvic belt screws; this is sometimes used to stabilize long bone
c. Pelvic sling and vertebral fractures. B. A pelvic belt is used to treat
d. Buck's traction back pain and does not provide traction prior to hip
arthroplasty.
, Final Exam - Med Surg
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C. A pelvic sling is used to stabilize pelvic fractures, not
hip fractures.
3. A nurse is caring for a client with A. "You'll have considerably less pain with the traction in
a hip fracture who has Buck's ex- place."
tension traction in place. Which of C. "The traction will help decrease muscle spasms."
the following pieces of information D. "The weights act as a pulling force to keep your leg
should the nurse give the client and hip still."
about this type of traction? (Select Pain is usually more severe without the traction. Buck's
all that apply.) extension traction uses weights to help decrease muscle
spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps
a. "You'll have considerably less stabilize the hip and leg preoperatively.
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."
4. A nurse is caring for a client who C. With the leg on the affected side abducted---The
is scheduled to undergo surgery nurse should plan to place the client with the leg ab-
to repair an open hip fracture. In ducted on the affected side postoperatively. Adduction
which of the following positions or external rotation of the leg will cause the hip to
should the nurse plan to place the dislocate.
client postoperatively?
a. With the leg on the affected side
adducted
, Final Exam - Med Surg
Study online at https://quizlet.com/_iipxx9
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
5. A nurse is assessing a client who C. Chest petechiae--- The nurse should identify chest
has a fractured left femur and is in petechiae as an indication of fat embolism syndrome.
skeletal traction. Which of the fol- Clients who have fractures of the long bones such as
lowing findings should the nurse the femur are at increased risk of fat emboli. Fat emboli
report to the provider? typically occur 12 to 48 hours after the injury when fat
droplets from the marrow enter into the systemic circu-
a. Ecchymosis of the thigh lation and are deposited in the lungs. The nurse should
b. Serous drainage at the pin site immediately notify the provider because the client could
c. Chest petechiae progress to acute respiratory failure.
d. Muscle spasms in the left leg
6. A nurse is preparing to care for a A. Offering the client a diet high in fluid and fiber----
client who is in balanced skeletal A client who is immobile is at risk of constipation. The
traction to stabilize a femur frac- nurse should encourage a diet high in fluid and fiber to
ture. Which of the following actions promote gastrointestinal function.
should the nurse include in the
client's plan of care? Incorrect Answers:
B. Active range of motion of the unaffected limbs is
a. Offering the client a diet high in encouraged to prevent muscle wasting; however, active
fluid and fiber range of motion of a limb in traction is not feasible, as
b. Encouraging active range of mo- the traction apparatus limits mobility.
tion of the affected leg C. Once the weights are in place, the nurse should not
c. Removing the weights prior to remove them.
repositioning the client 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.
, Final Exam - Med Surg
Study online at https://quizlet.com/_iipxx9
d. Inspecting pin sites every 24 hr
for drainage
7. A nurse is caring for a client who B. Have the client use a trapeze to pull himself up while
is in skeletal traction following a ensuring the weight hangs freely---The nurse should
femur fracture. On entering, the ensure that traction weight is hanging freely. The client
nurse finds that the client has slid can use an overhead trapeze bar to move up in bed,
toward the foot of the bed, and or the nurse can assist the client while making sure to
the traction weight is resting on the maintain proper alignment of the extremity.
floor. Which of the following actions
should the nurse take?
a. Remove the weight temporarily
to reposition the client to the cor-
rect alignment in bed
b. Have the client use a trapeze to
pull himself up while ensuring the
weight hangs freely
c. Lift the rope off the pulley while
the client rocks back and forth to
reposition himself
d. Lift the weight manually while
another staff member moves the
client up in bed
8. A nurse delegates the collection D. Right communication--- The situation could have
of a client's temperature to an as- been avoided if the right communication was given by
sistive personnel (AP). The nurse the nurse to the AP. The right communication entails
notes in the documentation that providing clear, concise instructions regarding the task,
the AP obtained the client's ax- including the objective, limits, and expectations.
illary temperature; however, the
nurse wanted an oral temperature.
