ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 40 : Musculoskeletal Care Modalities Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
Correct Answer: C
Rationale: The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.
Question 5 of 5
A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
Correct Answer: D
Rationale: Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.