Preview Extract
Chapter 57
1. Which findings would indicate a change in the client’s condition that would relate to a
compromised ulnar nerve integrity following a surgical repair of the elbow?
1. Inability to make the “ok” sign by bringing the thumb to the fourth or fifth finger
2. Pain radiating down from the wrist to the middle finger
3. Edema in the forearm that is ranked 3+
4. Notation of slight flexion limitation (less than 15 degrees) during passive ROM
Answer: Inability to make the “ok” sign by bringing the thumb to the fourth or fifth finger
Rationale:
Compression from bleeding or severe swelling at the ulnar nerve will not allow the finger and
thumb to be brought together without severe pain. Numbness in the ring and pinkie fingers is
a symptom of compartment syndrome, not a radiating pain from the wrist to the middle
finger. A 3+ edema postoperatively in the forearm is a symptom of impaired circulation above
the site of the edema, either from a tight dressing or cast; this is not a symptom of a
compromised ulnar integrity. Slight flexion limitations are a symptom of musculoskeletal
shortening that comes with disuse and are not a symptom related to ulnar integrity changes.
2. The nurse would include which assessments to evaluate the neurovascular status of a client
with a short-arm cast and arm sling?
Select all that apply.
1. Pain in or around the casted area
2. Paresthesia of the hand and/or some of the fingers
3. Paraplegia
4. Passive ROM limitations at the elbow
5. Peripheral muscle tone loss
Answer: 1. Pain in or around the casted area
2. Paresthesia of the hand and/or some of the fingers
Rationale:
Pain in or around the casted area. Pain is related to nerve and blood vessel compression that
would indicate a compromised neurovascular integrity. Additional Ps that are noted include:
paresthesia, paralysis, pallor, pulse changes. Paresthesia of the hand and/or some of the
fingers. Paresthesia is related to nerve and blood vessel compression that would indicate a
compromised neurovascular integrity. Additional Ps that are noted include: pain, paralysis,
pallor, pulse changes. Paraplegia. Paraplegia is defined as the motor and sensory loss of the
lower extremities and does not relate to upper extremity assessments. Passive ROM
limitations at the elbow. Passive ROM limitations at the elbow relate to muscle, tendon, and
ligament limitations and not to the nerves or vascular supply. Peripheral muscle tone loss.
Peripheral muscle tone losses are related to wasting of muscle tissue from disuse, misuse, or
the absence of use over a period of time. Muscle tone loss does not relate to the neurovascular
integrity assessment of the arm.
3. Which action by the nurse would best assess a 30-year-old client for symptoms of
dehydration?
1. Pinching skin on distal extremity between thumb and index finger
2. Comparing daily weights on chart over several days
3. Comparing intake and output over several days
4. Asking the client about the degree of thirst present
Answer: Pinching skin on distal extremity between thumb and index finger
Rationale:
Pinching the skin on the distal extremity between thumb and index finger will evaluate the
degree of tent-like projection; observe the timing it requires to return to normal. Prolonged
return time will indicate a decreased hydration status or dehydration. Daily weight
comparison can give some indication of overall fluid gain or loss, but additional causes may
be present that do not directly focus on the process of evaluation for dehydration. Comparing
intake and output will help evaluate the overall fluid status but does not tell if the client is
dehydrated, since fluids may be retained at the kidneys and may balance intake but still leave
the cells of the body dehydrated. The degree of thirst declines with the aging process and
other disease processes and is not a good indicator of dehydration.
4. The nurse would immediately report to the surgeon which findings in a client who had a
total knee replacement within the last 24 hours?
1. Capillary refill time of 5 seconds in the toes of the surgical leg
2. Slight pallor and skin coolness bilaterally
3. Diminished sensations in both legs and feet
4. Motor strength of 4 in the unaffected leg
Answer: Capillary refill time of 5 seconds in the toes of the surgical leg
Rationale:
Capillary refill times of less than 3 seconds are considered normal; it is prolonged in this
client, which might indicate compromised arterial flow in the surgical leg, and notification is
necessary. Pallor and cool skin temperature can reflect arterial flow decreases, but in this
client, it is bilateral in nature; it needs further investigation but it is not urgent and probably
not related to the surgery itself and does not require immediate notification. Diminished
sensations in both legs are a reflection of prolonged neurovascular changes and should be
compared to the presurgical status; it is probably not related to the surgery itself and
immediate notification is not required. Motor strength in the unaffected leg of 4 does not
require immediate notification to the health care provider, and it is probably not related to the
surgery.
5. The nurse would recognize the need for additional teaching in a postoperative posterior hip
replacement client when which of the following activities was observed. The client:
1. Used a regular-height toilet seat.
2. Used the abductor pillow while in bed.
3. Kept the affected leg and foot turned upright while in bed.
4. Kept the operative leg straight when getting out of bed, while using the arms to push up.
Answer: Used a regular-height toilet seat.
Rationale:
The toilet seat height needs to be raised to prevent overextension of the hip joint; therefore,
additional teaching is needed to prevent complications from the posterior hip replacement. An
abductor pillow is required to keep the hip in proper alignment and to prevent it from popping
out of place. An upright position will keep the leg and hip in proper alignment to prevent
displacement; the leg is not turned inward for the same reason. Keeping the leg straight and
using the arms will prevent displacement from twisting the hip when attempting to get out of
bed.
6. The nurse would understand the need for additional teaching for home management for a
client who had hip replacement when the client states, “I will:
1. Sit down in a chair to reach items below the waist height.”
2. Use a shower chair and raised toilet seat when performing hygiene.”
3. Have a ‘reacher’ to access things on the floor.”
4. Remove loose carpets or objects in walkways.”
Answer: Sit down in a chair to reach items below the waist height.” Rationale:
• Sitting down in a chair and then trying to reach below the waist height is still placing the hip
at risk of displacement due to an angle that is less than 90 degrees. Additional teaching is
required. Suggestions should include placing objects at the waist height or using a reacher to
assist without additional bending or twisting of the hips.
• A shower chair and raised toilet seat are keeping the hips at the correct angle to prevent
displacement.
• Using a reacher will prevent bending or stooping that might cause hip displacement.
• Loose carpets and objects in walkways may cause unnecessary falls and further injure the
client and/or hip replacement itself.
7. What would be the first action by the nurse for a client with a hip arthroplasty when the
affected leg was noted to be rotated outward, pale in coloring, diminishing pulses palpated,
skin temperature cool to touch, and shortening in length noted?
1. Ask about changes in pain levels.
2. Call the health care provider.
3. Replace the leg and foot to proper alignment with toes upward.
4. Reinforce proper positioning by putting the abductor pillow in place.
Answer: Ask about changes in pain levels.
Rationale:
Asking about changes in pain levels will indicate the compromise of bone and tissue
alignment. Increased pain and the absence of pain are both caused by pressure on nerves and
blood vessels when the hip is misaligned. Assessment is the first action prior to calling the
health care provider. Gathering all information prior to notifying the health care provider will
allow faster a decision-making process and better communication about the client’s current
status. Replacing the leg and foot to proper alignment, prior to understanding what
mechanism is present in the misalignment, would increase risk for additional damage to the
hip. This is not a nursing role and should be performed by health care providers trained to do
so. Placing the abductor pillow can also increase harm or risk of potential damage once the
leg is misaligned. The shortening of the hip shows that the hip is out of the socket and needs
professional replacement by a trained health care provider. Moving the leg should not be
done until the health care provider is present.
8. Which activity would be inappropriate to include in the plan of care for the first few hours
after a hip arthroplasty?
1. Ambulation with assistance using a walker
2. Incentive spirometry every 2 hours while awake
3. Lab comparison of hemoglobin and hematocrit to presurgery levels
4. Application of bilateral sequential compressive devices
Answer: Ambulation with assistance using a walker
Rationale:
Ambulation with a walker and assistance is begun the first day postoperatively. During the
first few hours after surgery, fluid volumes, respiratory functions, pain management, bed
positioning (abductor pillow), and bleeding are the priority of care. Getting out of bed to a
chair begins the first day postop. Incentive spirometry is begun in the immediate
postoperative period to prevent pulmonary complications. Hemoglobin and hematocrit levels
need to be closely assessed for internal bleeding and blood losses that might have occurred in
surgery and immediately postoperatively. Replacement therapy may be required if severe.
Hypoxia from low RBC will delay healing and tissue repairs and increase risk of
complications. Bilateral sequential compression devices (SCDs) are applied to prevent deep
vein thrombosis, which is a common complication of postoperative orthopedic clients.
Prevention is the best treatment; therefore, low-weight molecular heparin and SCDs are used
prophylactically.
9. If the 5 Ps of assessments for neurovascular status are present in a long-leg casted client,
the nurse would plan for what action to improve the neurovascular status?
1. Bi-valving the cast
2. Complete removal of the cast and replacement by skeletal traction
3. Elevation of the head of the bed (HOB)
4. Reassessment after the application of ice packs over the intact cast
Answer: Bi-valving the cast
Rationale:
Bi-valving the cast will allow for expansion of tissue that is swollen and direct assessment of
the extremity while maintaining bone alignment. The cast may be the source of a
compartment syndrome by limiting the potential swelling and compressing blood vessels that
diminish the blood supply to the distal portion of the extremity. Removal of the cast will
decrease the risk for the restriction of tissue swelling but does not maintain bone alignment.
Skeletal traction would keep the bones aligned but requires additional surgical placement and
increases risk of infection that is unrelated to the swelling causing the neurovascular
compromise. Elevating the HOB will increase dependent edema in the lower extremities and
will not reduce the neurovascular compression that is caused by the swelling in the casted leg.
Application of ice will reduce swelling in the leg but will not increase the blood flow to the
lower extremity fast enough to prevent potentially permanent damage to the leg. Relief of the
pressure inside the cast is needed immediately to prevent additional or permanent damage
from compromised blood flow to the distal portion of the lower extremity.
10. One of the nursing actions includes turning, coughing, and deep breathing the client every
2 hours; what assessment is needed to validate the effectiveness of these actions?
1. Assessment of bilateral lung sounds
2. Documenting the blood pressure to compare the trends
3. Monitoring intake and output
4. Assess carotid pulses for bruits
Answer: Assessment of bilateral lung sounds
Rationale:
Assessment of bilateral lung sounds will evaluate the effectiveness of pulmonary exchanges
of air and the possible fluid buildup that would diminish or prevent air flow in the bases of
the lungs from atelectasis. Trending the blood pressures will show hemodynamic status but
does not address the atelectasis and pulmonary functions that are directly related to the
actions of turning, coughing, and deep breathing. Monitoring intake and output will show
fluid status that increases the risk of fluids in the lungs but will not be improved by the
actions of turning, coughing, and deep breathing. Assessment of the carotid pulses for bruits
is used to show vascular status and is not impacted by pulmonary status that is related to
turning, coughing, and deep breathing.
11. What would be the nurse’s next action with the following findings noted upon assessment
of a client postarthroplasty: tachypnea, air hunger, hypoxia, O2 sat of 86%, decreasing mental
status, and petechiae?
1. Prepare the client for immediate intubation and mechanical ventilation with PEEP.
2. Raise the head of the bed (HOB) and encourage coughing every hour.
3. Call a code for potential cardiac arrest situation.
4. Apply oxygen at 3 to 4 liters /minute and then call the health care provider.
Answer: Prepare the client for immediate intubation and mechanical ventilation with PEEP.
Rationale:
The symptoms are related to severely compromised pulmonary status, probably acute
respiratory distress syndrome (ARDS), which is related to a fat emboli blocking the
pulmonary vessel and inactivating surfactant. Intubation and mechanical ventilation with
PEEP (positive end-expiratory pressure) are needed to maximize air exchange and treat
symptoms until the condition resolves. Raising the HOB will improve gas exchange slightly
by allowing the diaphragm to assist by gravitational pull to expand the chest, but since the
problem is not expansion of the chest but obstruction of the pulmonary vessels by fat emboli,
the condition will not improve. Calling for a code related to cardiac arrest is not appropriate
at this time since the heart is not the problem; the pulmonary status is what needs to be
addressed first. Application of oxygen will improve the availability of oxygen within the
lungs but does not improve the perfusion of air exchange; since the pulmonary vessel is
obstructed by fat emboli the normal respiratory effort is not enough pressure to force oxygen
to the smaller vessels. Therefore, PEEP is needed to open up smaller vessels to maximize air
exchange while under pressure.
12. Following extensive spinal surgery, which action by the nurse would be prudent to
prevent a common complication related to spinal swelling?
1. Administration of a stool softener and/or laxative with the return of bowel sounds
2. Immediate removal of a Foley in the PACU to prevent potential infections
3. Encouragement of the semi-Fowler’s position for the first 24 hours
4. Forcing fluids greater than 100 mL/hour once tolerating oral fluids
Answer: Administration of a stool softener and/or laxative with the return of bowel sounds
Rationale:Swelling in the spine following extensive surgery can cause compression on the
innervations of bowel and bladder functions. Prevention of constipation caused by narcotics,
bed rest, anesthesia, and nerve compression will minimize the risk of straining to evacuate the
bowel by prophylactically giving stool softeners and/or laxatives prior to actual need.
Immediate removal of the Foley in the PACU is not recommended due to the increased risk
of swelling innervations for bladder functions; but within 24 hours after surgery if the client
is getting up the Foley is removed to minimize risk of infections. Intermittent catherizations
are used if the client is unable to void. A semi-Fowler’s position is contraindicated due to the
risk of spinal fluid losses that occur in surgical repairs. A flat position is recommended to
minimize the risk of spinal headaches that can occur with spinal fluid losses during surgery.
In addition, a flat position is strongly recommended to minimize the bone stability or the risk
of trauma to the surgical site. Often the orders are to lie in bed or be up walking and to not
twist or turn to avoid mal-alignment of the surgical repair. Forcing fluids to 100 mL/hour may
be contraindicated for cardiac or renal clients and will not improve the risk for constipation or
bowel dysfunctions from spinal swelling.
13. The nurse would expect which action immediately following the treatment of a cerebral
spinal fluid leak in a post-spine-surgery client?
1. Keeping the client flat in bed for 2 hours
2. Raising the head of the bed (HOB) into a Trendelenburg position
3. Administering a bolus of IV fluids
4. Initiating strict isolation policies
Answer: Keeping the client flat in bed for 2 hours
Rationale:
Keeping the client flat in bed for 2 hours will allow the blood patch repair for the cerebral
spinal leak to clot and not migrate to other parts of the spine, thus allowing the seal to be
formed to minimize/stop the leaking of cerebral spinal fluids. Raising the HOB will increase
the risk of spinal leaking and increase the risk of spinal headache as the fluid is pulled by
gravity to the lower areas of the spinal column. Administration of increased fluids is not the
issue. It could increase the cerebral spinal pressure and increase the risk of rupture of the
patch if given too much in a short period of time. Therefore, it is not recommended to give a
bolus after a blood patch repair for the spinal leak. Strict isolation is not needed to prevent
potential for meningitis from the open wound in the spinal column. Sterile techniques and
sterile dressings should minimize that risk. It is not related to the administration of the blood
patch for the spinal leak itself.
14. Following hip surgery, which assistive device would be most helpful to be included in the
plan of care at all times to prevent fall injuries?
1. Ambulation with a walker
2. Assistance with two staff persons and the use of a safety belt
3. Bed rails X2 up at all times
4. Transportation by a wheelchair
Answer: Ambulation with a walker
Rationale:
Ambulation with a walker will give a stable support system to prevent falling injuries. The
ability to bear weight on the surgical leg is variable based upon the type of surgery
performed, but a walker will give a more stable base than a cane or crutch assistive device.
Assistance by two staff may or may not be needed at all times. The use of a safety belt is
strongly recommended no matter what number of assistants is present. As the client
progresses, assistance may be only one staff person. Complete independence with the use of a
walker is the goal prior to discharge. Bedrails up X2 is restrictive and can be considered
illegal restraint. The least restrictive environment is required by law. If confusion is a
problem, bed alarms or sitters may be more effective. Raising side rails for nursing
convenience is not acceptable practice. Use of a wheelchair is not encouraged.
15. In planning care for a client who has had a relapse of carpal tunnel syndrome, what
information is needed to prevent complications and allow maximization of healing? The
client needs to:
1. Wear a brace or wrist splint at night and during activities that aggravate the symptoms.
2. Exercise the wrist for complete rotation and ROM every 4 hours while awake.
3. Wear a cast for the first 3 weeks, followed by a protective splint for the next 6 to 8 weeks.
4. Wear an external hinge splint to support the wrist for several months.
Answer: Wear a brace or wrist splint at night and during activities that aggravate the
symptoms.
Rationale:
Wearing the brace or splint will keep the wrist in a natural position and prevent damage to the
surgically repaired area during sleep and activities that aggravate the symptoms. Exercising
the wrist will increase strain and cause more swelling that will delay the healing process.
Wearing a cast for several weeks followed by a sprint is related to wrist arthroplasty. A hinge
splint is designed for elbow surgery and not for wrists.
16. A client has had extensive ankle reconstruction and required a cast for stabilization. The
nurse would expect which educational topic to be included in the plan of care before
discharge?
1. Home management of the casted extremity
2. Application of heat four times each day
3. Weight-bearing training
4. Log-rolling techniques when getting out of bed
Answer: Home management of the casted extremity
Rationale:
Home management of the casted extremity is required to assist in self-care once discharged.
Care of the cast, assessments, limitations, and safety concepts need to be included in home
care. Heat is not applied to a cast due to increased risk of swelling and bleeding due to its
vasodilation effects. Ice can be applied with an on-off process lasting no longer than 30
minutes several times during the day. The ice will decrease swelling and pain by
vasoconstriction. Weight-bearing is contraindicated in extensive ankle surgery. Crutches or
walkers are needed for getting around safely. Log-rolling is done for back surgery to stabilize
the spinal column, not for ankle surgeries.
17. A subcutaneous pain pump is used for a client with a hip replacement surgery. Which
statement by the client during the first 24 hours after the surgery requires additional
assessment by the nurse?
1. “I feel numbness all the way down to my ankle.”
2. “I feel sleepy when I push my PCA (patient control analgesia) button.”
3. “I cannot believe how good I feel when I get up; I expected more pain.”
4. “I will need to use a toe-touch method even if there is no pain present.”
Answer: “I feel numbness all the way down to my ankle.”
Rationale:
Numbness that has extended to the ankle from a hip surgery means some compression is
present on the nerves that supply the foot with sensation. Additional assessments are required
to gather when and under what circumstances the numbness began and continued. Feeling
sleepy with the PCA is common since most of the drugs are narcotics or opiates that control
pain, and the CNS will be depressed also. PCA given with the SQ pain pump needs close
assessments to include the observations for potential overdosing of narcotics. Feeling sleepy
is an acceptable level of comfort. Inability to awaken the client would require additional
assessment for an overdose situation. With most hip replacements, the cause of the pain has
been removed. Bone is not on bone, infection or inflammation has been cleared out, and malalignment is corrected by the surgical procedure. The SQ pain pump gives direct relief and
minimizes the pain experienced in the immediate postoperative time frame. Toe-touch
walking is the correct method of ambulating until weight bearing is authorized by the health
care provider. Weight bearing is allowed based upon the type of replacement structures that
are involved in the surgery.
18. The nurse would expect to find which of the following orders to be included in pain
management following an above-the-knee amputation on a client?
Select all that apply.
1. Antiseizure medications
2. Nerve blocks
3. Transcutaneous electrical nerve stimulators (TENS)
4. Antidepressants
5. Relaxation exercises
Answer: 1. Antiseizure medications
2. Nerve blocks
3. Transcutaneous electrical nerve stimulators (TENS)
Rationale:
Antiseizure medications. Pain is characterized as acute and phantom in nature when dealing
with amputations; therefore, various nerve pathways and atypical medications have been able
to control pain as much or more than the traditional narcotics used for acute pain. Nerve
blocks. Nerve blocks work by blocking the pain pathways through low-level stimuli and not
allowing pain sensation to reach the brain centers of pain interpretation. Transcutaneous
electrical nerve stimulators (TENS). TENS work by blocking the pain pathways through lowlevel stimuli and not allowing pain sensation to reach the brain centers of pain interpretation.
Antidepressants. Pain is characterized as acute and phantom in nature when dealing with
amputations; therefore, various nerve pathways and atypical medications have been able to
control pain as much or more than the traditional narcotics used for acute pain. Relaxation
exercises. Relaxation exercises are used most often with chronic pain management. Normally
relaxation will not assist with a new postoperative client who is in pain.
19. When planning care for the orthopedic surgical client, the nurse would include which
approach?
1. Anticipatory pain management prior to therapy
2. Allowing family to assist in pushing the patient-controlled analgesia (PCA) button
3. Administering pain medications only while awake
4. Assessing vital signs to evaluate the degree of pain
Answer: Anticipatory pain management prior to therapy
Rationale:
Anticipatory pain management will improve the efforts during therapy to speed up the
recovery process. Better pain management that is more consistently given will improve
outcomes of recovery and client satisfaction. No one should be allowed to push the PCA
button except the client. Nursing staff and visitors are not the individuals experiencing the
pain; only the client should push the PCA button to regulate the dosage given based upon his
or her perceptions. Pain medications should be given around the clock for more effective
management of pain at all times. Additional dosages may be needed during increased periods
of activity, but by keeping a regulated amount of pain medication present within the body, the
muscles are more relaxed and the client is better able to tolerate therapy. Vital signs do not
always reflect the degree of pain experienced by the client. Chronic pain management clients
with long-term pain issues may not have the same sympathetic responses that are experienced
by those in acute pain. Pain is a perception of the individual and should not be judged by the
nurse.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
