Chapter 65: Nursing Management: Musculoskeletal Trauma and
Orthopedic Surgery: Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient in the emergency department who has a soft tissue
injury and an open leg fracture. Which of the following actions should the nurse
implement first?
A. If dislocation, apply compression bandage
B. Realignment of the bone(s)
C. Administer tetanus with an open fracture
D. Apply heat to the affected area
Answer: C
Explanation: With an open fracture, tetanus prophylaxis is a critical first step to prevent
infection. A compression bandage is not applied if dislocation is suspected. The nurse should
apply ice, not heat. Bone realignment is not attempted by the nurse.
2. The nurse is caring for a patient who has a cast in place after fracturing the radius
and the patient asks when the cast can be removed. Which of the following information
related to the length of time that the cast will need to remain in place should the nurse
tell the patient?
A. Several months
B. At least 3 weeks
C. Until swelling of the wrist has resolved
D. Until x-rays show complete bony union
Answer: B
Explanation: While bone healing (ossification) begins around 3 weeks post-injury, a cast is
typically needed for at least this duration to provide initial stability. Complete bony union
takes much longer (months to a year). Resolution of swelling does not indicate bone healing.
3. The nurse is caring for a patient who has a long-arm plaster cast applied for
immobilization of a fractured left radius. Which of the following actions should the
nurse implement until the cast has completely dried?
A. Keep the left arm in a dependent position.
B. Handle the cast with the palms of the hands.
C. Place gauze around the cast edge to pad any roughness.
D. Cover the cast with a small blanket to absorb the dampness.
Answer: B
Explanation: Handling a wet plaster cast with the palms prevents creating pressure points or
indentations inside the cast that could cause skin breakdown. The arm should be elevated to
reduce swelling. Petalling the cast edges and avoiding covers are done after the cast is dry.
,4. The nurse is caring for a patient who is 1 day postoperative below-the-knee
amputation who indicates pain in the amputated limb. Which of the following actions is
best for the nurse to take?
A. Explain the reasons for the phantom limb pain.
B. Administer prescribed analgesics to relieve the pain.
C. Loosen the compression bandage to decrease incisional pressure.
D. Remind the patient that this phantom pain will diminish over time.
Answer: B
Explanation: Phantom limb pain is real and should be treated with appropriate analgesics.
While patient education about the phenomenon and its typical course is important, the
immediate priority is pain relief. The compression bandage should remain in place to control
swelling and shape the residual limb.
5. The nurse is preparing a patient for discharge 4 days after insertion of a femoral
head prosthesis using a posterior approach. Which of the following patient statements
indicate a need for additional discharge instructions?
A. "I should not cross my legs while sitting."
B. "I will use a toilet elevator on the toilet seat."
C. "I will have someone else put on my shoes and socks."
D. "I can sleep in any position that is comfortable for me."
Answer: D
Explanation: After a posterior approach hip replacement, the patient must avoid positions
that cause hip flexion greater than 90 degrees and internal rotation to prevent dislocation.
Sleeping positions must be regulated to maintain these precautions. The other statements
show correct understanding of hip precautions.
6. The nurse is caring for a patient with a left femur fracture who has a hip spica cast
applied. Which of the following nursing interventions should be included in the plan of
care?
A. Avoid placing the patient in the prone position.
B. Use the cast support bar to reposition the patient.
C. Ask the patient about any abdominal discomfort or nausea.
D. Discuss the reasons for remaining on bed rest for several weeks.
Answer: C
Explanation: A hip spica cast can put pressure on the abdomen, leading to cast syndrome
(superior mesenteric artery syndrome), which presents with abdominal pain, nausea, and
vomiting. The cast support bar should not be used for repositioning as it can break the cast.
Patients can be turned prone once the cast is dry and may ambulate with assistance.
,7. The nurse is caring for a patient in the emergency department who has possible left
lower leg fractures. Which of the following actions should the nurse implement initially?
A. Elevate the left leg.
B. Splint the lower leg.
C. Obtain information about the tetanus immunization status.
D. Check the popliteal, dorsalis pedis, and posterior tibial pulses.
Answer: D
Explanation: The initial nursing action for any potential fracture is a thorough neurovascular
assessment. This must be done before and after any intervention like splinting or elevation.
Tetanus status is only relevant if there is an open wound.
8. The nurse is caring for a patient who has been hospitalized for 3 days with a hip
fracture who has sudden onset shortness of breath and tachypnea. The patient tells the
nurse, "I feel like I am going to die!" Which of the following actions should the nurse
take first?
A. Stay with the patient and offer reassurance.
B. Administer the prescribed PRN oxygen at 4 L/minute.
C. Check the patient's legs for swelling or tenderness.
D. Notify the health care provider about the symptoms.
Answer: B
Explanation: The patient's symptoms are classic for a pulmonary embolism or fat embolism,
both risks after a fracture. The first action is to address the impaired gas exchange by
administering oxygen. Reassurance is important, but physiological stability is the priority.
Assessment for DVT and notifying the provider follow oxygen administration.
9. The nurse is providing discharge teaching to a patient who has a short-arm plaster
cast applied. Which of the following patient statements indicate a good understanding of
the discharge teaching?
A. "I can get the cast wet as long as I dry it right away with a hair dryer."
B. "I should avoid moving my fingers and elbow until the cast is removed."
C. "I will apply an ice pack to the cast over the fracture site for the next 24 hours."
D. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."
Answer: C
Explanation: Applying ice over the cast for the first 24 hours helps reduce swelling and pain.
Plaster casts must be kept dry. Patients should be encouraged to move the joints above and
below the cast. Nothing should be inserted inside the cast.
10. The nurse is caring for a patient with Buck's traction who had an intracapsular
fracture of the left femur. Which of the following actions should the nurse take to
evaluate the effectiveness of Buck's traction?
, A. Assess for hip contractures.
B. Monitor for hip dislocation.
C. Check the peripheral pulses.
D. Ask about left hip pain level.
Answer: D
Explanation: A primary goal of Buck's traction is to reduce muscle spasms and associated
pain at the fracture site. Therefore, a reduction in pain indicates effectiveness. Contractures
and dislocation are not typical concerns with this type of traction. Checking pulses is
important for neurovascular assessment but does not directly evaluate traction effectiveness.
11. The nurse is preparing a patient with lower leg fracture and an external fixation
device in place for discharge. Which of the following information should the nurse
include in the discharge teaching?
A. "You will need to assess and clean the pin insertion sites daily."
B. "The external fixator can be removed during the bath or shower."
C. "You will need to remain on bed rest until bone healing is complete."
D. "Prophylactic antibiotics are used until the external fixator is removed."
Answer: A
Explanation: Meticulous pin site care is essential to prevent infection. The external fixator is
a permanent device until the fracture heals and cannot be removed for bathing. Patients are
encouraged to be mobile, not on bed rest. Prophylactic antibiotics are not routinely
prescribed.
12. The nurse is caring for a patient who is a baseball pitcher and had an arthroscopic
repair of a rotator cuff injury performed in same-day surgery. Which of the following
information should be included in the patient's postoperative teaching plan?
A. "You have an appointment with a physical therapist for tomorrow."
B. "You can still play baseball but you will not be able to return to pitching."
C. "The doctor will use the drop-arm test to determine the success of surgery."
D. "Leave the shoulder immobilizer on for the first few days to minimize pain."
Answer: A
Explanation: Physical therapy begins early (often the next day) after rotator cuff repair to
prevent joint stiffness and maintain range of motion. While an immobilizer is used initially,
prolonged immobilization is avoided. The drop-arm test is a diagnostic tool, not a
postoperative assessment. With successful rehabilitation, a return to pitching may be possible.
13. The nurse is caring for a patient who has had an open reduction and internal
fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg
which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot
is cool. Which of the following actions should the nurse take next?
Orthopedic Surgery: Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient in the emergency department who has a soft tissue
injury and an open leg fracture. Which of the following actions should the nurse
implement first?
A. If dislocation, apply compression bandage
B. Realignment of the bone(s)
C. Administer tetanus with an open fracture
D. Apply heat to the affected area
Answer: C
Explanation: With an open fracture, tetanus prophylaxis is a critical first step to prevent
infection. A compression bandage is not applied if dislocation is suspected. The nurse should
apply ice, not heat. Bone realignment is not attempted by the nurse.
2. The nurse is caring for a patient who has a cast in place after fracturing the radius
and the patient asks when the cast can be removed. Which of the following information
related to the length of time that the cast will need to remain in place should the nurse
tell the patient?
A. Several months
B. At least 3 weeks
C. Until swelling of the wrist has resolved
D. Until x-rays show complete bony union
Answer: B
Explanation: While bone healing (ossification) begins around 3 weeks post-injury, a cast is
typically needed for at least this duration to provide initial stability. Complete bony union
takes much longer (months to a year). Resolution of swelling does not indicate bone healing.
3. The nurse is caring for a patient who has a long-arm plaster cast applied for
immobilization of a fractured left radius. Which of the following actions should the
nurse implement until the cast has completely dried?
A. Keep the left arm in a dependent position.
B. Handle the cast with the palms of the hands.
C. Place gauze around the cast edge to pad any roughness.
D. Cover the cast with a small blanket to absorb the dampness.
Answer: B
Explanation: Handling a wet plaster cast with the palms prevents creating pressure points or
indentations inside the cast that could cause skin breakdown. The arm should be elevated to
reduce swelling. Petalling the cast edges and avoiding covers are done after the cast is dry.
,4. The nurse is caring for a patient who is 1 day postoperative below-the-knee
amputation who indicates pain in the amputated limb. Which of the following actions is
best for the nurse to take?
A. Explain the reasons for the phantom limb pain.
B. Administer prescribed analgesics to relieve the pain.
C. Loosen the compression bandage to decrease incisional pressure.
D. Remind the patient that this phantom pain will diminish over time.
Answer: B
Explanation: Phantom limb pain is real and should be treated with appropriate analgesics.
While patient education about the phenomenon and its typical course is important, the
immediate priority is pain relief. The compression bandage should remain in place to control
swelling and shape the residual limb.
5. The nurse is preparing a patient for discharge 4 days after insertion of a femoral
head prosthesis using a posterior approach. Which of the following patient statements
indicate a need for additional discharge instructions?
A. "I should not cross my legs while sitting."
B. "I will use a toilet elevator on the toilet seat."
C. "I will have someone else put on my shoes and socks."
D. "I can sleep in any position that is comfortable for me."
Answer: D
Explanation: After a posterior approach hip replacement, the patient must avoid positions
that cause hip flexion greater than 90 degrees and internal rotation to prevent dislocation.
Sleeping positions must be regulated to maintain these precautions. The other statements
show correct understanding of hip precautions.
6. The nurse is caring for a patient with a left femur fracture who has a hip spica cast
applied. Which of the following nursing interventions should be included in the plan of
care?
A. Avoid placing the patient in the prone position.
B. Use the cast support bar to reposition the patient.
C. Ask the patient about any abdominal discomfort or nausea.
D. Discuss the reasons for remaining on bed rest for several weeks.
Answer: C
Explanation: A hip spica cast can put pressure on the abdomen, leading to cast syndrome
(superior mesenteric artery syndrome), which presents with abdominal pain, nausea, and
vomiting. The cast support bar should not be used for repositioning as it can break the cast.
Patients can be turned prone once the cast is dry and may ambulate with assistance.
,7. The nurse is caring for a patient in the emergency department who has possible left
lower leg fractures. Which of the following actions should the nurse implement initially?
A. Elevate the left leg.
B. Splint the lower leg.
C. Obtain information about the tetanus immunization status.
D. Check the popliteal, dorsalis pedis, and posterior tibial pulses.
Answer: D
Explanation: The initial nursing action for any potential fracture is a thorough neurovascular
assessment. This must be done before and after any intervention like splinting or elevation.
Tetanus status is only relevant if there is an open wound.
8. The nurse is caring for a patient who has been hospitalized for 3 days with a hip
fracture who has sudden onset shortness of breath and tachypnea. The patient tells the
nurse, "I feel like I am going to die!" Which of the following actions should the nurse
take first?
A. Stay with the patient and offer reassurance.
B. Administer the prescribed PRN oxygen at 4 L/minute.
C. Check the patient's legs for swelling or tenderness.
D. Notify the health care provider about the symptoms.
Answer: B
Explanation: The patient's symptoms are classic for a pulmonary embolism or fat embolism,
both risks after a fracture. The first action is to address the impaired gas exchange by
administering oxygen. Reassurance is important, but physiological stability is the priority.
Assessment for DVT and notifying the provider follow oxygen administration.
9. The nurse is providing discharge teaching to a patient who has a short-arm plaster
cast applied. Which of the following patient statements indicate a good understanding of
the discharge teaching?
A. "I can get the cast wet as long as I dry it right away with a hair dryer."
B. "I should avoid moving my fingers and elbow until the cast is removed."
C. "I will apply an ice pack to the cast over the fracture site for the next 24 hours."
D. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."
Answer: C
Explanation: Applying ice over the cast for the first 24 hours helps reduce swelling and pain.
Plaster casts must be kept dry. Patients should be encouraged to move the joints above and
below the cast. Nothing should be inserted inside the cast.
10. The nurse is caring for a patient with Buck's traction who had an intracapsular
fracture of the left femur. Which of the following actions should the nurse take to
evaluate the effectiveness of Buck's traction?
, A. Assess for hip contractures.
B. Monitor for hip dislocation.
C. Check the peripheral pulses.
D. Ask about left hip pain level.
Answer: D
Explanation: A primary goal of Buck's traction is to reduce muscle spasms and associated
pain at the fracture site. Therefore, a reduction in pain indicates effectiveness. Contractures
and dislocation are not typical concerns with this type of traction. Checking pulses is
important for neurovascular assessment but does not directly evaluate traction effectiveness.
11. The nurse is preparing a patient with lower leg fracture and an external fixation
device in place for discharge. Which of the following information should the nurse
include in the discharge teaching?
A. "You will need to assess and clean the pin insertion sites daily."
B. "The external fixator can be removed during the bath or shower."
C. "You will need to remain on bed rest until bone healing is complete."
D. "Prophylactic antibiotics are used until the external fixator is removed."
Answer: A
Explanation: Meticulous pin site care is essential to prevent infection. The external fixator is
a permanent device until the fracture heals and cannot be removed for bathing. Patients are
encouraged to be mobile, not on bed rest. Prophylactic antibiotics are not routinely
prescribed.
12. The nurse is caring for a patient who is a baseball pitcher and had an arthroscopic
repair of a rotator cuff injury performed in same-day surgery. Which of the following
information should be included in the patient's postoperative teaching plan?
A. "You have an appointment with a physical therapist for tomorrow."
B. "You can still play baseball but you will not be able to return to pitching."
C. "The doctor will use the drop-arm test to determine the success of surgery."
D. "Leave the shoulder immobilizer on for the first few days to minimize pain."
Answer: A
Explanation: Physical therapy begins early (often the next day) after rotator cuff repair to
prevent joint stiffness and maintain range of motion. While an immobilizer is used initially,
prolonged immobilization is avoided. The drop-arm test is a diagnostic tool, not a
postoperative assessment. With successful rehabilitation, a return to pitching may be possible.
13. The nurse is caring for a patient who has had an open reduction and internal
fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg
which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot
is cool. Which of the following actions should the nurse take next?
