Musculoskeletal - Medsurg ATI
a. Toes cold to the touch
The nurse should monitor for and re-
port manifestations of compartment syn-
drome following internal fixation. There-
fore, the nurse should contact the
A nurse is assessing a client who is 48 hr provider immediately if the client's toes
postoperative following open reduction are cold to the touch.
and internal fixation of a fractured tibia.
Which the following findings should the b.The nurse should identify serous
nurse report to the provider? drainage from the pin sites as an expect-
a. Toes cold to the touch ed finding during the first 2 to 3 days
b. Serous drainage from the pin sites following the procedure.
c. Blanching of the toenail beds with c. As part of measuring capillary refill,
pressure the nurse should press the nail bed long
d. Pink tissue around the fixator insertion enough to produce a blanching appear-
sites ance. Therefore, the nurse does not need
to report this finding.
d. The nurse should identify pink to red
tissue at the fixator insertion sites as an
expected finding during the first 2 to 3
days following the procedure.
a. "This type of pain usually decreases
over time as the limb becomes less sen-
A nurse is caring for a client who had a sitive."
below-the-knee amputation for gangrene The nurse should recognize that the
of the right foot. The client reports sensa- client is reporting phantom limb pain, a
tions of burning and crushing pain in the frequent complication following amputa-
toes of the right foot. Which of the follow- tion. The nurse should instruct the client
ing statements should the nurse make? that the sensation should decrease over
a. "This type of pain usually decreases time. The nurse should recognize the
over time as the limb becomes less sen- pain, provide treatment, and handle the
sitive." limb gently to decrease the risk of trig-
b. "Try to look at the surgical wound as a gering pain.
reminder the limb is gone."
c. "Use a cold compress intermittently to b. This statement by the nurse does not
decrease these pain sensations." address the client's current concerns.
d. "Grief over the lost limb can some- c. The nurse should instruct the client
to use heat and massage, along with
pharmacological interventions, to man-
, Musculoskeletal - Medsurg ATI
age this type of pain.
d. The nurse should validate the client's
times cause denial that the limb is really report of pain and treat it accordingly. The
gone." client is not exhibiting denial; therefore,
this statement by the nurse is not appro-
priate.
a. Use a hair dryer on a cool setting to
blow air into the cast.
The nurse should provide relief for the re-
A nurse is caring for a client who had
port of itching by blowing cool air into the
a fiberglass cast placed on her left arm
cast using a hair dryer on a cool setting
several hours ago and now reports itch-
or an empty 60-mL plunger syringe.
ing under the cast. Which of the following
actions should the nurse plan to take?
b.The nurse should recognize that cast
a. Use a hair dryer on a cool setting to
bivalving is used relieve pressure when
blow air into the cast.
a cast becomes too tight on the affected
b. Ask the provider to bivalve the cast.
extremity.
c. Provide the client with a sterile cotton
c. The nurse should instruct the client not
swab to rub the affected skin.
to place any foreign object under the cast
d. Wrap the extremity with a dry heating
to prevent injury to the skin.
pad.
d. The nurse should avoid using heat on a
casted extremity because it can increase
edema.
b. Pulmonary embolus
Immobility following musculoskeletal
trauma places the client at an increased
risk for pulmonary embolus. The client
A nurse is caring for a client who has a
might also exhibit tachycardia, chest pe-
pelvic fracture. The client reports sudden
techiae, and have a decreased SaO2.
shortness of breath, stabbing chest pain,
The nurse should notify the rapid re-
and feelings of doom. The nurse should
sponse team immediately.
identify that the client is experiencing
which of the following complications?
a. The nurse should expect productive
a. Pneumonia
cough and pleural pain as findings of
b. Pulmonary embolus
pneumonia, which is a complication of
immobility following pelvic fracture.
c. The nurse should expect tracheal de-
viation and absence of breath sounds on
a. Toes cold to the touch
The nurse should monitor for and re-
port manifestations of compartment syn-
drome following internal fixation. There-
fore, the nurse should contact the
A nurse is assessing a client who is 48 hr provider immediately if the client's toes
postoperative following open reduction are cold to the touch.
and internal fixation of a fractured tibia.
Which the following findings should the b.The nurse should identify serous
nurse report to the provider? drainage from the pin sites as an expect-
a. Toes cold to the touch ed finding during the first 2 to 3 days
b. Serous drainage from the pin sites following the procedure.
c. Blanching of the toenail beds with c. As part of measuring capillary refill,
pressure the nurse should press the nail bed long
d. Pink tissue around the fixator insertion enough to produce a blanching appear-
sites ance. Therefore, the nurse does not need
to report this finding.
d. The nurse should identify pink to red
tissue at the fixator insertion sites as an
expected finding during the first 2 to 3
days following the procedure.
a. "This type of pain usually decreases
over time as the limb becomes less sen-
A nurse is caring for a client who had a sitive."
below-the-knee amputation for gangrene The nurse should recognize that the
of the right foot. The client reports sensa- client is reporting phantom limb pain, a
tions of burning and crushing pain in the frequent complication following amputa-
toes of the right foot. Which of the follow- tion. The nurse should instruct the client
ing statements should the nurse make? that the sensation should decrease over
a. "This type of pain usually decreases time. The nurse should recognize the
over time as the limb becomes less sen- pain, provide treatment, and handle the
sitive." limb gently to decrease the risk of trig-
b. "Try to look at the surgical wound as a gering pain.
reminder the limb is gone."
c. "Use a cold compress intermittently to b. This statement by the nurse does not
decrease these pain sensations." address the client's current concerns.
d. "Grief over the lost limb can some- c. The nurse should instruct the client
to use heat and massage, along with
pharmacological interventions, to man-
, Musculoskeletal - Medsurg ATI
age this type of pain.
d. The nurse should validate the client's
times cause denial that the limb is really report of pain and treat it accordingly. The
gone." client is not exhibiting denial; therefore,
this statement by the nurse is not appro-
priate.
a. Use a hair dryer on a cool setting to
blow air into the cast.
The nurse should provide relief for the re-
A nurse is caring for a client who had
port of itching by blowing cool air into the
a fiberglass cast placed on her left arm
cast using a hair dryer on a cool setting
several hours ago and now reports itch-
or an empty 60-mL plunger syringe.
ing under the cast. Which of the following
actions should the nurse plan to take?
b.The nurse should recognize that cast
a. Use a hair dryer on a cool setting to
bivalving is used relieve pressure when
blow air into the cast.
a cast becomes too tight on the affected
b. Ask the provider to bivalve the cast.
extremity.
c. Provide the client with a sterile cotton
c. The nurse should instruct the client not
swab to rub the affected skin.
to place any foreign object under the cast
d. Wrap the extremity with a dry heating
to prevent injury to the skin.
pad.
d. The nurse should avoid using heat on a
casted extremity because it can increase
edema.
b. Pulmonary embolus
Immobility following musculoskeletal
trauma places the client at an increased
risk for pulmonary embolus. The client
A nurse is caring for a client who has a
might also exhibit tachycardia, chest pe-
pelvic fracture. The client reports sudden
techiae, and have a decreased SaO2.
shortness of breath, stabbing chest pain,
The nurse should notify the rapid re-
and feelings of doom. The nurse should
sponse team immediately.
identify that the client is experiencing
which of the following complications?
a. The nurse should expect productive
a. Pneumonia
cough and pleural pain as findings of
b. Pulmonary embolus
pneumonia, which is a complication of
immobility following pelvic fracture.
c. The nurse should expect tracheal de-
viation and absence of breath sounds on
