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MED SURG ATI ADVANCED FINAL EXAM
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MED SURG ATI ADVANCED FINAL EXAM
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MED SURG ATI ADVANCED FINAL EXAM
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MED SURG ATI ADVANCED FINAL EXAMA nurse is caring for a client who has a fractured hip and was placed in Buck's
traction 4 hr ago. Which of the following actions should the nurse take?
a. Inspect the client's skin underneath the boot every 12 hr
b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr
c. Remove the weights from the traction while repositioning the client in bed
d. Loosen the ropes if the client reports muscle spasms in the affected extremity -
ANSWER: B. Encourage the client to perform dorsiflexion of the affected extremity
every 2 hr ---The nurse should encourage the client to perform dorsiflexion of the
affected extremity every 2 hours to assess if the client is experiencing nerve damage.
Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the
nurse should notify the provider immediately.
Incorrect Answers:
A. The nurse should inspect the client's skin underneath the boot for irritation,
increased swelling, and skin breakdown every 8 hours.
C. The weights should never be removed without a prescription from the provider.
The purpose of the weights is to decrease muscle spasms as a result of the hip
fracture.
D. The ropes of the traction should never be loosened. This can affect the traction
and increase the client's muscle spasms.
A nurse is caring for a client who has a fractured right hip. Which of the following
types of traction should the nurse expect the client to have prior to hip arthroplasty
surgery?
a. Balanced skeletal traction
b. Pelvic belt
c. Pelvic sling
d. Buck's traction - ANSWER: D. Buck's traction---Buck's traction is used prior to hip
arthroplasty to maintain alignment and prevent muscle spasms prior to surgery.
Incorrect Answers:
A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not
the hip. Skeletal traction involves the surgical insertion of pins, tongs, wires, or
screws; this is sometimes used to stabilize long bone and vertebral fractures. B. A
pelvic belt is used to treat back pain and does not provide traction prior to hip
arthroplasty.
C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in
place. Which of the following pieces of information should the nurse give the client
about this type of traction? (Select all that apply.)
,a. "You'll have considerably less pain with the traction in place."
b. "You'll have the traction in place for a week or so."
c. "The traction will help decrease muscle spasms."
d. "The weights act as a pulling force to keep your leg and hip still."
e. "We have to make sure the weights are just barely touching the floor." - ANSWER:
A. "You'll have considerably less pain with the traction in place."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
Pain is usually more severe without the traction. Buck's extension traction uses
weights to help decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force
helps stabilize the hip and leg preoperatively.
A nurse is caring for a client who is scheduled to undergo surgery to repair an open
hip fracture. In which of the following positions should the nurse plan to place the
client postoperatively?
a. With the leg on the affected side adducted
b. With the hip externally rotated on the affected side
c. With the leg on the affected side abducted
d. With the hip flexed to 90° on the affected side - ANSWER: C. With the leg on the
affected side abducted---The nurse should plan to place the client with the leg
abducted on the affected side postoperatively. Adduction or external rotation of the
leg will cause the hip to dislocate.
A nurse is assessing a client who has a fractured left femur and is in skeletal traction.
Which of the following findings should the nurse report to the provider?
a. Ecchymosis of the thigh
b. Serous drainage at the pin site
c. Chest petechiae
d. Muscle spasms in the left leg - ANSWER: C. Chest petechiae--- The nurse should
identify chest petechiae as an indication of fat embolism syndrome. Clients who
have fractures of the long bones such as the femur are at increased risk of fat
emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets
from the marrow enter into the systemic circulation and are deposited in the lungs.
The nurse should immediately notify the provider because the client could progress
to acute respiratory failure.
A nurse is preparing to care for a client who is in balanced skeletal traction to
stabilize a femur fracture. Which of the following actions should the nurse include in
the client's plan of care?
a. Offering the client a diet high in fluid and fiber
b. Encouraging active range of motion of the affected leg
c. Removing the weights prior to repositioning the client
, d. Inspecting pin sites every 24 hr for drainage - ANSWER: A. Offering the client a diet
high in fluid and fiber---- A client who is immobile is at risk of constipation. The nurse
should encourage a diet high in fluid and fiber to promote gastrointestinal function.
Incorrect Answers:
B. Active range of motion of the unaffected limbs is encouraged to prevent muscle
wasting; however, active range of motion of a limb in traction is not feasible, as the
traction apparatus limits mobility.
C. Once the weights are in place, the nurse should not remove them.
D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours
due to the risk of infection.
A nurse is caring for a client who is in skeletal traction following a femur fracture. On
entering, the nurse finds that the client has slid toward the foot of the bed, and the
traction weight is resting on the floor. Which of the following actions should the
nurse take?
a. Remove the weight temporarily to reposition the client to the correct alignment in
bed
b. Have the client use a trapeze to pull himself up while ensuring the weight hangs
freely
c. Lift the rope off the pulley while the client rocks back and forth to reposition
himself
d. Lift the weight manually while another staff member moves the client up in bed -
ANSWER: B. Have the client use a trapeze to pull himself up while ensuring the
weight hangs freely---The nurse should ensure that traction weight is hanging freely.
The client can use an overhead trapeze bar to move up in bed, or the nurse can
assist the client while making sure to maintain proper alignment of the extremity.
A nurse delegates the collection of a client's temperature to an assistive personnel
(AP). The nurse notes in the documentation that the AP obtained the client's axillary
temperature; however, the nurse wanted an oral temperature. The nurse should
identify which of the following rights of delegation should have prevented this
situation from occurring?
a. Right task
b. Right circumstance
c. Right person
d. Right communication - ANSWER: D. Right communication--- The situation could
have been avoided if the right communication was given by the nurse to the AP. The
right communication entails providing clear, concise instructions regarding the task,
including the objective, limits, and expectations.
A client who reports shortness of breath requests the nurse's help in changing
positions. After repositioning the client, which of the following actions should the
nurse take next?
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