Final Exam - Med Surg with complete solutions

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 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 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. 00:07 01:08 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." 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 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 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 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 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 B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely---The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity. A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify which of the following rights of delegation should have prevented this situation from occurring? a. Right task b. Right circumstance c. Right person d. Right communication D. Right communication--- The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations. A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a. Encourage the client to take deep breaths b. Observe the rate, depth, and character of the client's respirations c. Prepare to administer oxygen d. Give the client a back rub to promote relaxation B. Observe the rate, depth, and character of the client's respirations--- The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position D. Place the client in an upright position---Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow. A nurse is preparing to administer packed RBCs to a client who is anemic. Which of the following actions should the nurse take? (Select all that apply.) A. Insert a 23-gauge angiocatheter with an IV adaptor B. Check to determine the packed RBCs are less than 1 week old C. Administer the packed RBCs over a 6-hr period D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride B. Check to determine the packed RBCs are less than 1 week old D. Ask another nurse to check the packed RBCs' label against the medical record E. Prime the transfusion tubing with 0.9% sodium chloride The nurse should check to determine that the packed RBCs are less than 1 week old; if the blood is older, the RBCs become fragile, break easily, and release potassium into the blood steam. In addition, the nurse should ask another nurse to check the packed RBCs label against the medical record for safety verification. The nurse should ensure that the client's complete name and identification number match and that the blood group name and number are correct. If there is any type of discrepancy, the nurse should not infuse the blood and should notify the blood bank. Finally, the nurse should prime the transfusion tubing with 0.9% sodium chloride. Other solutions such as Ringer's lactate and dextrose in water can cause clotting or hemolysis of the packed RBCs. A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort A. Elevate the affected leg--- The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.