ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 51 : Care of Patients with Musculoskeletal Trauma Questions
Question 1 of 5
A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?
Correct Answer: A
Rationale: Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a secondary benefit, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage, but these are not the primary purposes of skeletal traction.
Question 2 of 5
A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
Correct Answer: D
Rationale: These clinical manifestations indicate inflammation and possible infection. Obtaining a prescription to culture the drainage is the appropriate action to identify and treat a potential infection. Decreasing traction weight or scrubbing the area could exacerbate the issue, and a warm compress may not address the underlying infection.
Question 3 of 5
Which intervention should the nurse include in this client's plan of care for a client recovering from a below-the-knee amputation?
Correct Answer: B
Rationale: Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractures and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to reposition, move, and exercise frequently, and therefore should not implement strict bedrest.
Question 4 of 5
An emergency department nurse stages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?
Correct Answer: A
Rationale: A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed to ensure client safety.
Question 5 of 5
A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.