ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 61 Questions
Question 1 of 5
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?
Correct Answer: B
Rationale: After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.
Question 2 of 5
The nurse is caring for a patient with a fractured right femur who is not a candidate to repair the femur immediately. What intervention should the nurse anticipate the physician will order to relieve muscle spasm and pain until surgery is performed?
Correct Answer: B
Rationale: If surgery for a fracture cannot be performed right away, Buck's traction or other skin traction may be applied to relieve muscle spasm and pain until surgery is performed. The other distractors all require surgical intervention.
Question 3 of 5
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
Question 4 of 5
The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse: 'If my leg is really gone, then why am I having such bad pain?' What is an appropriate response by the nurse?
Correct Answer: B
Rationale: Phantom pain is pain or other discomfort, such as burning, tingling, throbbing, or itching. Pain felt from the phantom limb can be an extremely serious problem in relation to the client's emotional status and ability to use prosthesis. The other responses are nontherapeutic.
Question 5 of 5
A patient is scheduled for hip replacement surgery in a month. Which statement made by the client demonstrates understanding for the preoperative instructions?
Correct Answer: B
Rationale: If a client is scheduled for joint replacement or other surgery, the client should be instructed to withhold aspirin prior to the surgery as per physician's instructions. The client should not be instructed to withhold antihypertensive medications to avoid a rebound hypertension. Cold packs, not heat packs, will be applied to reduce pain and edema after surgery. The client will require physical therapy after surgery and will not be able to walk until day 2 with assistance.