NUR 211 Test #3
The nurse is performing an assessment on a client admitted with a fractured left humerus. When
the client moves the extremity, the nurse notes the presence of a grating sound. Which is the
nurse's best intervention>?
A. Immobilize the arm
B. Perform range of motion
C. Monitor for other signs of infection
D. Administer steroids - ANS Immobilize the arm
The grating sound heard when the affected part is moved is known as crepitation. This sound is
created by bone fragments. Because bone fragments may be present, the nurse should
immobilize the client's arm and tell him or her not to move the arm. The nurse should not move
the extremity for range of motion. The grating sound does not indicate infection. Steroids
wouldn't be indicated.
Fracture left humerus, grating sound noted upon movement: immobilize the arm
An older client has returned to the surgical unit after a total hip replacement. The client is
confused and restless. What intervention by the nurse is most important to prevent injury?
A. Administer mild sedation
B. Keep all four side rails up
C. Restrain the client's hands.
D. Use an abduction pillow - ANS Use an abduction pillow
Older clients often have trouble metabolizing anesthetics and pain medication, leading to
confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should
use an abduction pillow once the client cannot follow directions at this time. Sedation may
worsen the client's mental status and should be avoided. Using all four side rails may be
considered a restraint. Hand restraints are not necessary in this situation.
Older post op pt developing wound infection: the client is confused
MS for potential complications, RN assess for what - ANS Falls, skin breakdown, fatigue
AIDS pt cryptococcal meningitis - ANS Initiate seizure precautions with padded side rails
MS pt asks why beta1 nec. - ANS This med will help decrease the number and severity of
relapses
DC total hip replacement except - ANS Cont. passive motion machine
, Pelvic fracture - complication - ANS Hematuria
Elder, fell, immobile 3 days, all require immediate intervention except - ANS Heart rate 98
Spinal precautions, neck injury, MVA, priority in ED - ANS Checking cervical collar placed
correctly
Characteristics of fractures in children - ANS Rapidly healing is inversely related to the age of
child
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 130/86 mmHg
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 3 seconds - ANS Traction weights are resting on the floor
The immediate action of the nurse should be to reapply the weights to give traction to the
fracture. 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.
Fracture, skeletal traction, immediate action: the traction weights are resting on the floor
A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The
client reports pain in the right foot. Which prescribed medication should the nurse administer
first?
A. Intravenous morphine
B. Oral acetaminophen
C. Intravenous calcitonin
D. Oral ibuprofen - ANS Intravenous calcitonin
The client is experiencing phantom limb pain, which usually manifests as intense burning,
crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce
phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb
pain as they are residual limb pain. Oral acetaminophen and ibuprofen are not used in treating
phantom limb pain.
AKA right leg complains pain in right foot, intervention: adm IV calcitonin
Systemic lupus DC after exacerbation, family disruption - ANS Help the pt create backup plan
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