The nurse is performing an assessment on a client admitted with a fractured left humerus. When the client moves the extremity, the nurse notes the presence of a grating sound. Which is the nurse's best intervention>? A. Immobilize the arm B. Perform range of motion C. Monitor for other signs of ...
NUR 211 Test 3 Questions and Correct
Answers
The nurse is performing an assessment on a client admitted with a fractured left
humerus. When the client moves the extremity, the nurse notes the presence of a
grating sound. Which is the nurse's best intervention>?
A. Immobilize the arm
B. Perform range of motion
C. Monitor for other signs of infection
D. Administer steroids ✅Immobilize the arm
The grating sound heard when the affected part is moved is known as crepitation. This
sound is created by bone fragments. Because bone fragments may be present, the
nurse should immobilize the client's arm and tell him or her not to move the arm. The
nurse should not move the extremity for range of motion. The grating sound does not
indicate infection. Steroids wouldn't be indicated.
Fracture left humerus, grating sound noted upon movement: immobilize the arm
An older client has returned to the surgical unit after a total hip replacement. The client
is confused and restless. What intervention by the nurse is most important to prevent
injury?
A. Administer mild sedation
B. Keep all four siderails up
C. Restrain the client's hands.
D. Use an abduction pillow ✅Use an abduction pillow
Older clients often have trouble metabolizing anesthetics and pain medication, leading
to confusion or restlessness postoperatively. To prevent the hip from dislocating, the
nurse should use an abduction pillow once the client cannot follow directions at this
time. Sedation may worsen the client's mental status and should be avoided. Using all
four side rails may be considered a restraint. Hand restraints are not necessary in this
situation.
Older post op pt developing wound infection: the client is confused
MS for potential complications, RN assess for what ✅Falls, skin breakdown, fatigue
AIDS pt cryptococcal meningitis ✅Initiate seizure precautions with padded side rails
MS pt asks why beta1 nec. ✅This med will help decrease the number and severity of
relapses
, DC total hip replacement except ✅Cont. passive motion machine
Spinal precautions, neck injury, MVA, priority in ED ✅Checking cervical collar placed
correctly
Characteristics of fractures in children ✅Rapidly healing is inversely related to the age
of child
A nurse assesses a client with a fracture who is being treated with skeletal traction.
Which assessment should alert the nurse to urgently contact the health provider?
A. Blood pressure increases to 130/86 mmHg
B. Traction weights are resting on the floor
C. Oozing of clear fluid is noted at the pin site
D. Capillary refill is less than 3 seconds ✅Traction weights are resting on the floor
The immediate action of the nurse should be to reapply the weights to give traction to
the fracture. The health care provider must be notified that the weights were lying on the
floor, and the client should be realigned in bed. The clients blood pressure is slightly
elevated; this could be related to pain and muscle spasms resulting from lack of
pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill
time.
Fracture, skeletal traction, immediate action: the traction weights are resting on the floor
A nurse cares for a client recovering from an above-the-knee amputation of the right
leg. The client reports pain in the right foot. Which prescribed medication should the
nurse administer first?
A. Intravenous morphine
B. Oral acetaminophen
C. Intravenous calcitonin
D. Oral ibuprofen ✅Intravenous calcitonin
The client is experiencing phantom limb pain, which usually manifests as intense
burning, crushing, or cramping. IV infusions of calcitonin during the week after
amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not
as effective for phantom limb pain as they are residual limb pain. Oral acetaminophen
and ibuprofen are not used in treating phantom limb pain.
AKA right leg complains pain in right foot, intervention: adm IV calcitonin
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