med surg final exam (test bank) Questions and Answers with complete
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Course
Med surg
Institution
Med Surg
med surg final exam (test bank) Questions
and Answers with complete
A 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...
med surg final exam (test bank) Questions
and Answers with complete
A 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 - -
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
, med surg final exam (test bank) Questions
and Answers with complete
b. Pelvic belt
c. Pelvic sling
d. Buck's traction - -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." - -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."
, med surg final exam (test bank) Questions
and Answers with complete
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 - -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 - -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
, med surg final exam (test bank) Questions
and Answers with complete
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 - -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?
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