A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? A. Blood pressure increases to 136/86 B. Traction weights are resting on the floor C. Oozing of clear fluid is noted at the pin sit...
NUR 211 Final Exam Questions and
Correct Answers
A nurse assesses a client with a fracture who is being treated with skeletal traction.
Which assessment should alert the nurse to urgently contact the health provider?
A. Blood pressure increases to 136/86
B. Traction weights are resting on the floor
C. Oozing of clear fluid is noted at the pin site
D. Capillary refill is less than three seconds ✅B. Traction weights are resting on the
floor
The immediate action of the nurse should be to reapply the weights to give traction to
the fractures. The health care provider must be notified that the weights were lying on
the floor, and the client should be realigned in bed. The client's blood pressure is slightly
elevated; this could be related to pain and muscle spasms resulting from lack of
pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill
time.
A nurse coordinates care for a client with a wet plaster cast. Which statement should
the nurse include when delegating care for this client to an UAP?
A. "Assess distal pulses for potential ACS"
B. "Turn the client every 3-4 hours to promote cast drying"
C. "Use a cloth-covering pillow to elevate the client's leg"
D. "Handle the cast with your fingertips to prevent indentation" ✅C. "Use a cloth-
covered pillow to elevate the client's leg."
When Delegating care to a UAP for a client with a wet plaster cast, the USP should be
directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic
pillow to promote drying. The client should be assessed for impaired arterial circulation,
a complication of ACS; however, the nurse should not delegate assessments to a UAP.
The client should be turned every 1-2 hours to allow air to circulate and dry all parts of
the cast. Providers should handle the cast with the palms to prevent indentations.
A nurse obtained the health history of a client with a fractured emu. Which factor
identified in the client's history should the nurse recognize as an aspect that may
impede healing of the fracture?
A. Sedentary Lifestyle
B. A 30-pack-year smoking history
C. Prescribe Doral contraceptives
D. Paget's disease ✅D. Paget's disease
, Paget's disease and bone cancer can cause pathologic fractures such as a fractured
femur that do not achieve total healing. The other factors do not impede healing but
may cause other health risks
An emergency department nurse cares for a client who sustained a crush injury to the
right lower leg. The client reports numbness and tingling in the affected leg. Which
action should the nurse take first?
A. Assess pedal pulses
B. Apply oxygen by NC
C. Increase the IV flow rate
D. Loosen the traction. ✅A. Assess the pedal pulses
These symptoms represent early warning signs of ACS. In ACS, sensory deficits such
as paresthesias precede changes in vascular or motor signs. IF the nurse finds a
decrease in pedal pulses, the health care provider should be notified as soon as
possible. V/S need to be obtained to determine if oxygen and IV fluids are necessary.
Traction, if implemented, should never be loosened without a provider's order.
A nurse assesses an older adult client who was admitted 2 days ago with a fractured
hip. The nurse notes that the client is confused and restless. The client's vital signs are
HR 98, RR 32, BP 132/78, and SpO2 88%. Which action should the nurse take first?
A. Administer oxygen via nasal cannula
B. Re-position to a high fowler's position
C. Increase the IV flow rate
D. Assess response to pain medications. ✅A. Administer oxygen via nasal cannula
The client is at a high risk for fat embolism and has some of the clinical manifestations
of AMS and dyspnea. Although this is a life-threatening emergency, the nurse should
take the time to administer oxygen first and then notify the health care provider. Oxygen
administration can reduce the risk for cerebral damage from hypoxia. The nurse would
not restrain a client who is confused without further assessment and orders. Sitting the
client in a high-fowler's position will not decrease hypoxia related to fat embolism. The
IV rate is not related. Pain medication most likely would not cause the client to be
restless.
A trauma nurse cares for several clients with fractures. Which client should the nurse
identify as at the highest risk for developing DVT?
A. An 18-year-old male athlete with a fractured clavicle
B. A 36-year-old female with type 2 diabetes and fractured ribs
C. A 55-year-old woman prescribed aspirin for RA
D. A 74-year-old man who smokes and has a fractured pelvis ✅D. A 74-year-old man
who smokes and has a fractured pelvis
DVT as a complication with bone fractures occur more often when fractures are
sustained in the lower extremities and the client has additional risk factors for thrombus
formation. Other risk factors include obesity, smoking, oral contraceptives, previous
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