PrepU Chapter 37: Management of Patients with Musculoskeletal Trauma

Column A
HR- 92
RR- 20/min
pH- 7.32
CO2- 35 mm Hg
HCO2- 20 mEq/L
PaO2- 62 mm Hg

Column B
HR-116
RR- 32/min
pH- 7.50
CO2- 30 mm Hg
HCO2- 24 mEq/L
PaO2- 55 mm Hg

Column C
HR- 88
RR- 16/min
pH- 7.48
CO2- 43 mm Hg
HCO2- 20 mEq/L
PaO2- 85 mm Hg

Column D
HR- 102
RR- 26/min
pH- 7.45
CO2- 37 mm Hg
HCO2- 20 mEq/L
PaO2- 72 mm Hg

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome?

Column A

Column B

Column C

Column D
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Terms in this set (73)
Column A
HR- 92
RR- 20/min
pH- 7.32
CO2- 35 mm Hg
HCO2- 20 mEq/L
PaO2- 62 mm Hg

Column B
HR-116
RR- 32/min
pH- 7.50
CO2- 30 mm Hg
HCO2- 24 mEq/L
PaO2- 55 mm Hg

Column C
HR- 88
RR- 16/min
pH- 7.48
CO2- 43 mm Hg
HCO2- 20 mEq/L
PaO2- 85 mm Hg

Column D
HR- 102
RR- 26/min
pH- 7.45
CO2- 37 mm Hg
HCO2- 20 mEq/L
PaO2- 72 mm Hg

Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome?

Column A

Column B

Column C

Column D
Correct response:
Column B

Explanation:
Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia and other manifestations of respiratory failure. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.
A client has been diagnosed with a muscle strain. What does the physician mean with the term "strain"?

stretched or pulled beyond its capacity

injury resulting from a blow or blunt trauma

injuries to ligaments surrounding a joint

subluxation of a joint
Correct response:
stretched or pulled beyond its capacity

Explanation:
A strain is an injury to a muscle when it is stretched or pulled beyond its capacity.
A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching?

"I'll need to keep several pillows between my legs at night."

"I need to remember not to cross my legs. It's such a habit."

"The occupational therapist is showing me how to use a sock puller to help me get dressed."

"I don't know if I'll be able to get off that low toilet seat at home by myself."
Correct response:
"I don't know if I'll be able to get off that low toilet seat at home by myself."

Explanation:
The client requires additional teaching if he is concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.
Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

Comminuted

Compression

Impacted

Greenstick
Correct response:
Impacted

Explanation:

An impacted fracture is one in which a bone fragment is driven into another bone fragment. A comminuted fracture is one in which the bone has splintered into several fragments. A compression fracture is one in which bone has been compressed. A greenstick fracture is one in which one side of the bon is broken and the other side is bent.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?

Arthrodesis

Hemiarthroplasty

Total arthroplasty

Osteotomy
Correct response:
Total arthroplasty

Explanation:
A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
A client presents at the emergency department with a compound fracture of the right femur. Skeletal traction is applied to align the bones. What type of traction would be used?

Steinmann traction
Buck's traction
Russell traction
Thomas splint
Correct response:
Steinmann traction

Explanation:
Skeletal traction is applied directly to a bone by using a wire (Kirschner), pin (Steinmann), or cranial tongs (Crutchfield). General or local anesthesia may be used when inserting these devices.
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is:

Risk for ineffective therapeutic regimen management

Disturbed body image

Situational low self-esteem

Risk for avascular necrosis of the joint
Correct response:
Risk for ineffective therapeutic regimen management

Explanation:
The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.
A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain?

A dull, deep, boring ache

Sharp and piercing

Similar to "muscle cramps"

Sore and aching
Correct response:
Sharp and piercing

Explanation:
The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed.

Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications.

Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?

Increased ability to stretch arm over the head
Difficulty lying on affected side
Pain worse in the morning
Minimal pain with movement
Correct response:
Difficulty lying on affected side

Explanation:
Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?

Consult a skin specialist.
Scrub the area vigorously to remove the crust.
Apply lotions and take warm baths or soaks.
Avoid exposure to direct sunlight.
Correct response:
Apply lotions and take warm baths or soaks.

Explanation:
The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure: the client that he or she won't be cut. that the cast cutter blade is new. that pedal pulses are present. that the leg will be as good as new.Correct response: the client that he or she won't be cut. Explanation: Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Fahrenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which complication? Atelectasis Hypovolemic shock Osteomyelitis Urinary retentionCorrect response: Hypovolemic shock Explanation: Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective? "I will wear a boot with weights attached." "A belt will go around my pelvis and weights will be attached." "The traction can be removed once a day so I can shower." "Metal pins will go through my skin to the bone."Correct response: "Metal pins will go through my skin to the bone." Explanation: In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain? Heterotopic ossification Epicondylitis Rotator cuff tears Acute compartment syndromeCorrect response: Rotator cuff tears Explanation: Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period? osteomyelitis hemorrhage infection hematomaCorrect response: osteomyelitis Explanation: Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed? The leg will look as it did prior to the cast being applied. The leg strength is enforced by the wearing of the cast. The leg will look moist and will have small bumps that will go away in a few days. The skin may be covered with a yellowish crust that will shed in a few days.Correct response: The skin may be covered with a yellowish crust that will shed in a few days. Explanation: Once the cast is off, the skin appears mottled and may be covered with a yellowish crust composed of accumulated body oil and dead skin. The client usually sheds this residue in a few days. The leg will not look as it did prior to the cast but will regain the same shape and status as the other leg. There should be no bumps underneath the cast. The leg may be weak and stiff for some time after the cast is removed, not stronger.Which is an inaccurate principle of traction? The weights are not removed unless intermittent treatment is prescribed. Skeletal traction is interrupted to turn and reposition the client. The client must be in good alignment in the center of the bed. The weights must hang freely.Correct response: Skeletal traction is interrupted to turn and reposition the client. Explanation: Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall? Impacted fracture Compound fracture Pathologic fracture Transverse fractureCorrect response: Pathologic fracture Explanation: A pathologic fracture is a fracture that occurs through an area of diseased bone and can occur without trauma or a fall. An impacted fracture is a fracture in which a bone fragment is driven into another bone fragment. A transverse fracture is a fracture straight across the bone. A compound fracture is a fracture in which damage also involves the skin or mucous membranes.A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. During postoperative recovery, what specific complication might develop in this client's case? pyelonephritis compartment syndrome subluxation All options are correct.Correct response: compartment syndrome Explanation: The nurse monitors the client for signs and symptoms of compartment syndrome such as unrelenting pain unrelieved by analgesics. Also, neurovascular checks are performed to help prevent this complication.A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? Apply the traction straps snugly. Remove the traction at least every 8 hours. Teach the client how to prevent problems caused by immobility. Assess the client's level of consciousness.Correct response: Teach the client how to prevent problems caused by immobility. Explanation: By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head? fat embolism avascular necrosis pulmonary embolism shockCorrect response: avascular necrosis Explanation: Avascular necrosis is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head.The nurse in an orthopedic clinic is caring for a new client. What sign or symptom would lead a nurse to suspect that a client has a rotator cuff tear? Pain worse in the morning Ability to stretch arm over the head Difficulty lying on affected side Minimal pain with movementCorrect response: Difficulty lying on affected side Explanation: Clients with a rotator cuff tear experience pain with movement and limited mobility of the shoulder and arm. They especially have difficulty with activities that involve stretching their arm above their head. Many clients find that the pain is worse at night and that they are unable to sleep on the affected side.The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? A fasciotomy An open reduction A total knee replacement A total hip replacementCorrect response: A fasciotomy Explanation: A treatment option for compartment syndrome is fasciotomy.Which term refers to an injury to ligaments and other soft tissues surrounding a joint? Strain Dislocation Subluxation SprainCorrect response: Sprain Explanation: A sprain is caused by a wrenching or twisting motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation or dislocation of joint surfaces. Strain refers to a muscle pull or tear.A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as? Sprain Compartment syndrome Volkmann's contracture SubluxationCorrect response: Subluxation Explanation: A partial dislocation is referred to as a subluxation. A Volkmann's contracture is a claw like deformity that results from compartment syndrome or obstructed arterial blood flow to the forearm and hand. Compartment syndrome is a condition in which a structure such as a tendon or nerve is constricted in a confined space and affects nerve innervation, leading to subsequent palsy. A sprain is injury to the ligaments surrounding the joint.A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose? subluxation contusion strain sprainCorrect response: contusion Explanation: A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A subluxation is a partial dislocation.An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? Remove the cast immediately. Notify the physician. Document the findings. Assess for pedal pulse and mobility of toes.Correct response: Notify the physician. Explanation: Indentations in the cast can cause skin irritation and breakdown. The physician needs to be notified to assess the need for a new cast or manipulation of the current cast to prevent the skin breakdown. The nurse will need to document the findings and actions taken to resolve the issue but cannot document actions without completing an action, such as notifying the physician. The cast does not need to be removed immediately. Pedal pulse will indicate whether a circulatory issue is present, but with the client being unresponsive, mobility of the toes cannot be assessed.The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician? Heart rate of 94 beats/minute Crackles in the lung bases Client complains of pain in the affected rib area when taking a deep breath Blood pressure of 140/90 mm HgCorrect response: Crackles in the lung bases Explanation: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? Prevent internal rotation of the affected leg. Keep the affected leg in a position of adduction. Use measures other than turning to prevent pressure ulcers. Keep the hip flexed by placing pillows under the client's knee.Correct response: Prevent internal rotation of the affected leg. Explanation: The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.A client sustains an injury to the ligaments surrounding a joint. What will the nurse identify this injury as? Fracture Strain Contusion SprainCorrect response: Sprain Explanation: A sprain is an injury to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. A fracture is a break in the continuity of a bone.Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia? Fat embolism syndrome (FES) Complex regional pain syndrome (CRPS) Disseminated intravascular coagulation (DIC) Avascular necrosis (AVN)Correct response: Disseminated intravascular coagulation (DIC) Explanation: DIC is a systemic disorder that results in widespread hemorrhage and microthrombosis with ischemia. AVN of the bone occurs when the bone loses its blood supply and dies. CRPS is a painful sympathetic nervous system problem. FES occurs when the fat globules released when the bone is fractured occludes the small blood vessels that supply the lungs, brain, kidneys, and other organs.A client with a fractured femur is placed in skeletal traction. Which intervention will increase client independence when moving in bed? Remind to use the heel of the unaffected foot to reposition. Apply a trapeze to the bed frame. Remove the weights prior to repositioning. Instruct to use the elbows to reposition.Correct response: Apply a trapeze to the bed frame. Explanation: To encourage movement, an assistive device called a trapeze can be suspended overhead within easy reach of the client. The trapeze helps the client move about in bed and move on and off the bedpan. The client's elbows frequently become sore, and nerve injury may occur if the client repositions by pushing on the elbows. Clients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. It is important to instruct clients not to use their heels or elbows to push themselves up in bed. The weights should not be removed to reposition the client or for any other reason.The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse? Hypoactive bowel sounds Crackles that clear with coughing Drainage from wound suction device = 100 ml Previous shift urine output = 500 mlCorrect response: Drainage from wound suction device = 100 ml Explanation: Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this? Impacted Comminuted Depressed CompoundCorrect response: Comminuted Explanation: A comminuted fracture may require open reduction and internal fixation. A compound fracture is one in which damage also involves the skin or mucous membranes. A depressed fracture is one in which fragments are driven inward. An impacted fracture is one in which a bone fragment is driven into another bone fragment.Which action would be most important postoperatively for a client who has had a knee or hip replacement? Assisting in early ambulation. Providing crutches to the client. Using a continuous passive motion (CPM) machine. Encouraging expressions of anxiety.Correct response: Assisting in early ambulation. Explanation: An anticoagulant therapy and early ambulation are important for clients who undergo a knee or hip replacement. A CPM machine or crutches may be provided when prescribed. It is important to encourage clients to express their feelings of anxiety or depression. This is more crucial for clients who undergo an amputation rather than for clients who undergo a replacement surgery.The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client? Do not flex the hip more than 120 degrees. Do not flex the hip more than 90 degrees. Do not flex the hip more than 60 degrees. Do not flex the hip more than 30 degrees.Correct response: Do not flex the hip more than 90 degrees. Explanation: Proper alignment and supported abduction are encouraged for hip repairs. Flexion of the hip more than 90 degrees can cause damage to the a repaired hip fracture.A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation? Flexion Abduction Adduction Internal rotationCorrect response: Abduction Explanation: The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion.A client had an above-the-knee amputation of the left leg related to complications from peripheral vascular disease. The nurse enters the client's room and observes the dressing and bed covers saturated with blood. What is the first action by the nurse? Reinforce the dressing. Apply a tourniquet. Notify the health care provider. Use skin clips to close the wound.Correct response: Apply a tourniquet. Explanation: Following an amputation, immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the client's bedside so that if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. The nurse immediately notifies the surgeon in the event of excessive bleeding.Which would be contraindicated as a component of self-care activities for the client with a cast? Cover the cast with plastic to insulate it Cushioning rough edges of the cast with tape Elevate the casted extremity to heart level frequently Do not attempt to scratch the skin under a castCorrect response: Cover the cast with plastic to insulate it Explanation: The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction? Perform ankle dorsiflexion three times per day. Apply heat to the fracture site. Apply ice to the fracture site. Use crutches for 1 week.Correct response: Apply ice to the fracture site. Explanation: Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. Applying heat to the fracture site may increase swelling and bleeding. Ankle dorsiflexion has no therapeutic use after a toe fracture. It's unlikely the client would need crutches after a toe fracture.After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis? Fat embolism Infection Volkmann's ischemic contracture Compartment syndromeCorrect response: Fat embolism Explanation: Fat embolism is a relatively rare but life-threatening complication of pelvis and long-bone fractures, arising 24 to 48 hours after the injury. It occurs when fat droplets released at the fracture site enter the circulation, become lodged in pulmonary capillaries, and break down into fatty acids. Because these acids are toxic to the lung parenchyma, capillary endothelium, and surfactant, the client may develop pulmonary hypertension. Signs and symptoms of fat embolism include an altered mental status, fever, tachypnea, tachycardia, hypoxemia, and petechiae. Compartment syndrome and infection may complicate any fracture and aren't specific to a pelvis fracture. Volkmann's ischemic contracture is a potential complication of a hand or forearm fracture.The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) Decreased sensory function Excruciating pain Capillary refill less than 3 seconds 2+ peripheral pulses in the affected distal pulse Loss of motionCorrect response: Decreased sensory function Excruciating pain Loss of motion Explanation: Clinical manifestations include dusky, pale appearance of the exposed extremity; cool skin temperature; delayed capillary refill; paresthesia; and unrelenting pain not relieved by position changes, ice, or analgesia. A hallmark sign is pain that occurs or intensifies with passive range of motion (Johnston-Walker & Hardcastle, 2011). The patient may complain that the cast, brace, or splint is too tight. The primary provider must be notified immediately.The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication? Contracture of the hip Dislocation of the hip Avascular necrosis of the hip Re-fracture of the hipCorrect response: Dislocation of the hip Explanation: Manifestations of a dislocated hip prosthesis are increased pain at the surgical site, acute groin pain in the affected leg, shortening of the leg, abnormal external or internal rotation, and limited movement of the fractured leg. The client may report a "popping" sensation in the hip.A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? Keeping a pillow between the client's legs at all times Maintaining the client in semi-Fowler's position Performing passive range-of-motion (ROM) exercises on the client's legs once each shift Turning the client from side to side every 2 hoursCorrect response: Keeping a pillow between the client's legs at all times Explanation: After open reduction with internal fixation, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period, because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After open reduction with internal fixation, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? Apply the traction straps snugly. Assess the client's level of consciousness. Remove the traction at least every 8 hours. Teach the client how to prevent problems caused by immobility.Correct response: Teach the client how to prevent problems caused by immobility. Explanation: By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. wound infection pneumonia diarrhea skin breakdownCorrect response: skin breakdown wound infection pneumonia Explanation: After surgery, the nurse implements measures to prevent skin breakdown, wound infection, pneumonia, constipation, urinary retention, muscle atrophy, and contractures.The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Delayed union Compartment syndrome Complex regional pain syndrome Fat embolism syndromeA client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? Contact the health care provider. Contact the nursing supervisor. Elevate the affected extremity. Administer oxygen.Correct response: Administer oxygen. Explanation: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the health care provider after administering oxygen.Which type of fracture involves a break through only part of the cross-section of the bone? Comminuted Incomplete Open ObliqueCorrect response: Incomplete Explanation: An incomplete fracture involves a break through only part of the cross-section of the bone. A comminuted fracture is one that produces several bone fragments. An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees.A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? Compound Spiral Greenstick ObliqueCorrect response: Compound Explanation: A compound fracture is a fracture in which damage also involves the skin or mucous membranes with the risk of infection great. A greenstick fracture is where one side of the bone is broken and the other side is bent; it does not protrude through the skin. An oblique fracture occurs at an angle across the bone but does not protrude through the skin. A spiral fracture twists around the shaft of the bone but does not protrude through the skin.A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses? maintaining adequate circulation ensuring surgery was successful ensuring there wasn't nerve damage during surgery typical postoperative nursing managementCorrect response: maintaining adequate circulation Explanation: Circulation, sensation, and mobility of exposed fingers or toes must be assessed every 1 to 2 hours to ensure neurovascular status is not compromised.A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied? Walking cast Short leg cast Hip spica cast Long leg castCorrect response: Short leg cast Explanation: A short leg cast extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. A long leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed. A walking cast is a short or long leg cast reinforced for strength. A hip spica cast encloses the trunk and a lower extremity.Which is not a guideline for avoiding hip dislocation after replacement surgery. Put a pillow between the legs when sleeping. Keep the knees apart at all times. Never cross the legs when seated. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.Correct response: The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Explanation: Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for? Open reduction and internal fixation of the left hip. Left hip arthroscopy Left hip arthroplasty Closed reduction of the left hip.Correct response: Left hip arthroplasty Explanation: Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm? Proper use of a sling Repositioning the arm in the cast Use of isometric exercises Abduction and adduction of the shoulderCorrect response: Use of isometric exercises Explanation: Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the client is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The client should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture? Encourage participation in ADLs Use frequent dependent positioning to prevent edema Promote intake of omega-3 fatty acids Administer prescribed enema to prevent constipationCorrect response: Encourage participation in ADLs Explanation: General nursing measures for a client with a fracture reduction include administering analgesics, providing comfort measures, encouraging participation with ADLs, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing the client for self-care. Omega-3 fatty acids have no implications on the diet of a client with a fracture reduction. Dependent positioning may increase edema because the extremity is below the level of the heart. While some pain medications may contribute to constipation, this intervention would be reserved for a client experiencing constipation and not as a preventative measure.A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client? Insertion of an external fixator Removal of the cast Cutting of a bivalve cast Cutting a cast windowCorrect response: Cutting a cast window Explanation: After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.Which is a hallmark sign of compartment syndrome? Motor weakness Pain Edema Weeping skin surfacesCorrect response: Pain Explanation: A hallmark sign of compartment syndrome is pain that occurs or intensifies with passive range of motion.In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? Carpal tunnel syndrome Compartment syndrome Disseminated intravascular coagulation Fat embolism syndromeCorrect response: Compartment syndrome Explanation: The nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable in a client with a dislocation to assess for compartment syndrome. It is a complication associated with dislocation. A client with a dislocation does not experience an increased risk of complications such as disseminated intravascular coagulation, carpal tunnel syndrome, or fat embolism syndrome.Which of the following are associated with compartment syndrome? Select all that apply. Tight bandages Casts Trauma from accidents Crushing injuries SurgeryCorrect response: Trauma from accidents Surgery Casts Tight bandages Crushing injuries Explanation: Risk factors for compartment syndrome include trauma from accidents, surgery, casts, tight bandages, and crushing injuries. In addition, it may be caused by any condition that increases the risk of bleeding or edema in a confined space including patients with soft tissue injury, without fractures, who are on anticoagulants or have bleeding dyscrasias.When discussing physical activities with the client who has just undergone a right total hip replacement, which instruction should the nurse provide? "Perform rotation exercises each day." "Limit hip flexion to 90 degrees." "Avoid weight bearing until the hip is completely healed." "Intermittently cross and uncross your legs several times each day."Correct response: "Limit hip flexion to 90 degrees." Explanation: The client should avoid all activities that can result in dislocation of the hip. The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis.A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse documents that this fracture is classified as what type of fracture? Incomplete Compression Closed StressCorrect response: Incomplete Explanation: A greenstick fracture involves a break through only part of the cross-section of the bone.A client asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse? "Elevating the extremity may increase your chances of compartment syndrome." "Elevating the leg might lead to a flexion contracture." "I am sorry. We ran out of pillows. I can elevate it on a few blankets." "You need to turn yourself side to side. If your leg is on a pillow, you would not be able to do that."Correct response: "Elevating the leg might lead to a flexion contracture." Explanation: Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the client's ability to use a prosthesis. The client does need to turn to both sides but might still be able to do it with the extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? Spontaneous pneumothorax Fat emboli Cardiac tamponade PneumoniaCorrect response: Fat emboli Explanation: After fracture of long bones or pelvic bones, or crush injuries, fat emboli frequently form. Fat embolism syndrome (FES) occurs when fat emboli cause morbid clinical manifestations. The classic triad of clinical manifestations of FES include hypoxemia, neurologic compromise, and a petechial rash (NAON, 2007), although not all signs and symptoms manifest at the same time (Tzioupis & Giannoudis, 2011). The typical first manifestations are pulmonary and include hypoxia and tachypnea.The nurse is caring for a client with a spica cast. What is the nurse's priority intervention? Position the client on the affected side. Keep the cast clean and dry. Keep the legs in abduction. Promote elimination with a regular bedpan.Correct response: Keep the cast clean and dry. Explanation: Keeping the cast clean and dry around the perineal opening is a priority. A spica cast has a built-in abduction bar. The client should be positioned on the unaffected side every 2 hours and prone twice a day. A fracture bedpan is easier to use for the client with a spica cast.A client who has sustained a fracture reports an increase in pain and decreased function of the affected extremity. What will the nurse suspect? Infection Avascular necrosis Hypovolemic shock Pulmonary embolismCorrect response: Avascular necrosis Explanation: Avascular necrosis refers to the death of the bone from insufficient blood supply, typically manifested by complaints of increased pain and decreased function. Fever or redness, purulent drainage, and swelling of the site would suggest infection. Respiratory distress would suggest a pulmonary embolism. Changes in vital signs, level of consciousness, and signs and symptoms of fluid loss would suggest hypovolemic shock.The nurse teaching the client with a cast about home care includes which instruction? Keep the cast below heart level Cover the cast with plastic or rubber Fix a broken cast by applying tape Dry a wet fiberglass cast thoroughly to avoid skin problemsCorrect response: Dry a wet fiberglass cast thoroughly to avoid skin problems Explanation: Instruct the client to keep the cast dry, to dry a wet fiberglass cast thoroughly to avoid skin problems, and not to cover it with plastic or rubber. A cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. A casted extremity should be elevated frequently to heart level to prevent swelling. A broken cast should be reported to the physician and the client should not attempt to fix it.To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan? Increase fiber intake. Remove the weights during linen changes. Increase calorie intake. Reduce fluid intake.Correct response: Increase fiber intake. Explanation: Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation.Colles fracture occurs in which area? Elbow Humeral shaft Clavicle Distal radiusCorrect response: Distal radius Explanation: A Colles fracture is a fracture of the distal radius (wrist). It is usually the result of a fall on an open, dorsiflexed hand.A client was playing softball and dislocated four fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as? External fixation Open reduction with internal fixation Open reduction Closed reductionCorrect response: Closed reduction Explanation: In a closed reduction, the bone is restored to its normal position by external manipulation. A bandage, cast, or traction then immobilizes the area. In an open reduction, the bone is surgically exposed in the operating room and realigned. If internal fixation is needed to stabilize a reduced fracture, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pin.A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth? Administration of antibiotics Administration of low-dose heparin Electrical stimulation Joint fusionCorrect response: Electrical stimulation Explanation: Delayed union may require surgical interventions to promote bone growth and correct the incorrect union. If necessary, prepare the client for use of electrical stimulation measures that promote bone growth, or for a bone graft. Administration of low-dose heparin would be used to prevent pulmonary embolism. Joint fusion may be used in the case of avascular necrosis. Administration of antibiotics would be used for the potential of infection or to treat an actual infection.A nurse is caring for a client who has had an amputation. What interventions can the nurse provide to foster a positive self-image? (Select all that apply.) Encouraging the client to care for the residual limb Allowing the client to express grief Introducing the client to local amputee support groups Encouraging the client to have family and friends view the residual limb to decrease self-consciousness Encouraging family and friends to refrain from visiting temporarily because this may increase the client's embarrassmentCorrect response: Encouraging the client to care for the residual limb Allowing the client to express grief Introducing the client to local amputee support group Explanation: The nurse helps the client set realistic rehabilitation goals and encourages the client to be an active participant in self-care. The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grieving process; support from family and friends promotes the patient's acceptance of the loss. Mental health and support group referrals may be appropriate. Although the nurse supports the client in coming to terms with the appearance and function of the residual limb, and in sharing feelings about the amputation with family and friends, viewing of the residual limb by family and friends is not a priority and may not be helpful for the client's well-being.The primary nursing intervention that will control swelling while treating a musculoskeletal injury is: Apply an elastic compression bandage. Immobilize the injured area. Elevate the affected area. Apply cold (moist or dry).Correct response: Elevate the affected area. Explanation: Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression. Refer to Box 42-1 in the text.