ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 40 : Musculoskeletal Care Modalities Questions
Question 1 of 5
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action?
Correct Answer: D
Rationale: Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.
Question 2 of 5
A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?
Correct Answer: B
Rationale: After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.
Question 3 of 5
A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient's affected limb are spastic. How does this change in muscle tone affect the patient's traction prescription?
Correct Answer: B
Rationale: The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.
Question 4 of 5
A patient is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
Correct Answer: A
Rationale: Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient's immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.
Question 5 of 5
A nurse is caring for a patient receiving skeletal traction. Due to the patient's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?
Correct Answer: B
Rationale:
To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.