CORRECT Answers
A patient has a fractured femur. Which finding would the The patient appears confused
nurse instruct the unlicensed assistive personnel (UAP) to
report immediately?
1. The patient reports pain
2. The patient appears confused
3. The patient's blood pressure is 136/88 mm Hg
4. The patient voided using the bedpan
After the nurse receives change-of-shift report, which A 28-year-old patient with a fracture who reports that the cast is tight
patient should be assessed first?
1. A 42-year-old patient with carpal tunnel syndrome who
reports pain
2. A 64-year-old patient with osteoporosis awaiting
discharge
3. A 28-year-old patient with a fracture who reports that
the cast is tight
4. A 56-year-old patient with a left leg amputation who
reports phantom pain
A patient with a fractured fibula is receiving skeletal The traction weights are resting on the floor
traction and has skeletal pins in place. What would the
nurse instruct the unlicensed assistive personnel (UAP) to
report immediately?
1. The patient wants to change position in bed
2. There is a small amount of clear fluid at the pin sites
3. The traction weights are resting on the floor
4. The patient reports pain and muscle spasm
The nurse is supervising a new graduate RN caring for a Encouraging the patient to go from a lying to a standing position
patient with a fracture of the right ankle who is at risk for
complications of immobility. For which action should the
supervising nurse intervene?
1. Encouraging the patient to go from a lying to a
standing position
2. Administering pain medication before the patient
begins exercises
3. Explaining to the patient and family the purpose of the
exercise program
4. Reminding the patient about the correct use of
crutches
Which nursing action is contraindicated when caring for a Handling the cast with fingertips
client with a newly applied long leg cast?
1. Elevating the cast on a pillow
2. Drying the cast by using a fan
3. Leaving the cast exposed to air
4. Handling the cast with fingertips
, A nurse suspects the development of compartment Escalating pain in the fingers
syndrome for a client who has sustained blunt trauma to
the forearm. For which early sign of compartment
syndrome should the nurse assess the client?
1. Warm skin at site of injury
2. Escalating pain in the fingers
3. Rapid capillary refill in affected hand
4. Bounding radial pulse in the injured arm
A client experiences a traumatic amputation of a leg in a Teaching residual limb care
motor vehicle accident. Which nursing intervention
initially should receive the lowest priority?
1. Teaching residual limb care
2. Monitoring hemoglobin levels
3. Maintaining the compression dressing
4. Using therapeutic interviewing techniques
A client has an amputation of a lower limb. What Lie on the abdomen 30 minutes four times daily
instructions should the nurse give the client to prevent a
hip flexion contracture?
1. Turn from side to side every 1 to 2 hours
2. Sit in a chair for 30 minutes three times a day
3. Lie on the abdomen 30 minutes four times daily
4. Perform quadriceps muscle setting exercises twice
daily
What should the nurse do to control edema of the Rewrap the elastic bandage as necessary
residual limb 1 week after a client has an above-the-knee
amputation?
1. Administer the prescribed diuretic
2. Restrict the client's oral fluid intake
3. Rewrap the elastic bandage as necessary
4. Keep the residual limb elevated on a pillow
What should be included in the nurse's instructions to Exercises with or without weights to strengthen the muscles of the upper
help a client prepare for walking with crutches? extremities
1. Use of the trapeze to strengthen the biceps muscles
2. Exercises with or without weights to strengthen the
muscles of the upper extremities
3. The importance of keeping the affected limb in
extension and abduction to prevent contractures
4. Isometric exercises of the hamstring muscles while
sitting in a chair until circulatory status is stable
What should the nurse do to promote early and efficient Turn the client to the prone position routinely
ambulation after a client has a midthigh amputation?
1. Keep the head of the bed elevated
2. Place the residual limb on a pillow
3. Turn the client to the prone position routinely
4. Encourage the client to lie on the unaffected side