ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 65 Questions
Question 1 of 5
The nurse is caring for a patient in the emergency department who has possible left lower leg fractures. Which of the following actions should the nurse implement initially?
Correct Answer: D
Rationale: The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.
Question 2 of 5
The nurse is caring for a patient with ulnar drift caused by rheumatoid arthritis (RA) who is scheduled for an arthroplasty of the hand. Which of the following patient statements indicate realistic expectation for the surgery?
Correct Answer: A
Rationale: The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.
Question 3 of 5
The nurse is caring for a patient in the emergency department following a motor vehicle accident who has massive right lower leg swelling. Which of the following actions will the nurse take first?
Correct Answer: C
Rationale: The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.
Question 4 of 5
The nurse is caring for a patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next?
Correct Answer: A
Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
Question 5 of 5
The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.