ATI - MUSCULOSKELETAL EXAM

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ATI - MUSCULOSKELETAL EXAM

89 terms NurseRBF2021 Preview ATI Res 74 terms sae A client has been admitted to the orthopedic floor to have a RKA performed. Which of the following statements demonstrates to the nurse that the client understands the preoperative teaching?"I will...

• have my knee placed in a continuous passive motion

machine for 24 hours a day b.ask for pain medicine whenever the pain gets bad

• wear elastic stockings on both legs until i am

discharged have to stay in bed for a week after my surgery

• wear elastic stockings on both legs until i am discharged

purpose of elastic stockings is to prevent thrombophlebitis, a common complication after orthopedic surgery

INCORRECT

• passive motion machine is usually for a few hours at a time and of a total of 8-12

hrs a day.

• client should ask for pain meds BEFORE the pain becomes severe
• Ambulation usually begins 48 hr following a TKA

A client sustains an open fracture of the left femur. An intramedullary pin is inserted, and the client is placed in skeletal traction. While performing the initial assessment, the nurse finds the client has slipped down toward the foot of the bed and the traction weight is resting on the floor. The appropriate nursing action is to...

• Remove the weight and move the client to the correct

alignment in bed

• check for movement of the toes in the left foot
• notify the attending orthopedic physician
• help the client use the trapeze to pull himself up in

bed

• help the client use the trapeze to pull himself up in bed

The traction is no longer effective when it is resting on the floor. The nurse should help the client resume his normal position in bed to reestablish traction

A client is discharged after having an open reduction and internal fixation of a fractured tibia with application of a plaster caste. The nurse teaches the client to evaluate for early signs of decreased circulation r/t post surgical edema. The teaching was understood when the client identifies a manifestation of decreased circulation as...

• Coldness of the toes
• Capillary refill of 3 seconds
• Blanching of the nail beds with pressure
• Pain at the surgical site
• Coldness of the toes

Decreased venous return from the constriction caused by a cast may lead to impaired circulation of the foot. Manifestations of impaired circualation include toes that are cold, numb, tingling, or swollen.A client with a radial fracture reports itching under the casted area. The appropriate nursing action to relieve itching is to...

• Use a hair dryer on a cool setting to blow air into the

cast B.elevate the affected extremity

• Provide a cotton swab to scratch the area
• Explain to the client that itching is an indication the

fracture is healing

• Use a hair dryer on a cool setting to blow air into the cast

The cool air will cause vasoconstriction and decrease neural transmission of sensation to the affected area

• days after fracturing his tibia playing lacrosse, a college

student is brought to the hospital with roommate who reports that client is not acting like himself and seems confused. The nurse notes that the client has a long leg cast on his right leg and that the client is disoriented to time and place. Vital signs reveal that the client is tachycardia and tachypneic, the nurse should assess the client for other signs of

• hypovolemic shock
• fat embolism
• thrombophlebitis
• bone malalignment
• fat embolism

Fat embolism syndrome follows long bone fractures. Young men with fractures are at increased riskk of fat embolism, Classic presentation consists of a asymptomatic interval followed by pulmonary and neurological manifestations, such as fever and cutaneous petechiae of the neck, chest, and abdomen.A patient asks the nurse the difference between Rheumatoid arthritis and osteoarthritis. The nurse responds, " Osteoarthritis is....

• autoimmune
• localized
• systemic
• bilateral
• localized

localized process associated with aging and can affect any joint

A diabetic client with a non-healing wound of the heel is diagnosed with osteomyelitis. The nurse anticipates the client's treatment regimen will include

• ice to the site to decrease edema
• application of a short leg cast to limit movement of the

involved ankle joint

• administration of glucocorticoids to decrease

inflammatory process

• insertion of a peripherally inserted catheter line for

long term IV antibiotics

• insertion of a peripherally inserted catheter line for long term IV antibiotics

Osteomyelitis is an acute or chronic bone infection Patient may eventually require amputation.A nurse is caring for a client who had BKA for gangrene of the foot. The client knows that the foot has been amputated, but reports to the nurse severe pain in the toes of the injured foot. The nurse should recognize this as

• an actual pain sensation
• delusional belief
• a referred postoperative incisional pain
• a defense mechanism of denial
• an actual pain sensation

phantom limp pain- severed peripheral nerve pathways A client with an ankle sprain is being discharged from the ER. To promote tissue healing and relieve discomfort, the nurse instructs the client to...a.continue typical activities with the ankle immobilized b.keep the extremity in a dependent position

• keep a loose dressing on the affected area
• apply cold compresses to the affected area
• apply cold compresses to the affected area

cold minimizes swelling and erythema to the affected area. However, cold compresses should not be applied continuously for more than 30 min A client is 3 days postoperative following a RHA. The client cries out in pain when transferred to a chair. Which of the following nursing observations should lead to the suspicion of a dislocated hip prosthesis

• bulging in the right hip area
• shortening of the right leg
• adduction of the left leg
• external rotation of the right leg
• shortening of the right leg

classic indicators of prosthetic dislocation:

• shortening of the leg
• abnormal rotation
• increased discomfort

INCORECT

• cause of pain will not result in any bulging
• The cause of clients pain will not result in changes to the unaffected leg
• The cause of the clients pain will cause internal rotation of the right leg

A client is on bed rest following a pelvic fracture when he suddenly becomes dyspneic and reports feeling short of breath, The nurse assesses the client and finds that tachycardia,hypotension, and tachypnea are occurring.The client's oxygen saturation is dropping rapidly. The nurse should identify that the client is exhibiting signs consistent with...

• pneumonia
• pulmonary emolus
• tension pneumothorax
• flail chest
• pulmonary emolus

patient who has a fracture and maintained on bed rest is at high risk for pulmonary embolism DUE TO venous status and hyper-coagulation.Typical presentation of a client with a a blood clot in the arterial structure of the

lung includes:

• difficulty breathing
• low blood pressure (hypotension)
• confusion and hypoxia
• high pulse (tachycardia).

INCORRECT:

• pneumonia can be a complication of immobility following pelvic fracture BUT

does not cause a sudden onset of difficult breathing or a rapid drop in oxygen saturation rate.On a health history form, a client being admitted to an outpatient surgery center for KA indicates taking celecoxib (celebrex) daily. Based on the medication, the nurse should suspect that the client has a history of...

• infection
• depression
• Rheumatoid arthritis
• seizures
• Rheumatoid arthritis

Celecoxib (celebrex)= nosteroidal anti-inflammatory cyclooxygenase-2 (COX02) inhibitor Used to relieve some manifestations caused by rheumatoid arthritis in adults A client involved in a motor vehicle crash sustained maxillofacial trauma from striking the windshield. The client receives inter maxillary fixation with interdental wiring. Postoperativiley, the client vomits clear liquids.Which of the following actions is appropriate for the nurse to take

• suction the emesis form the client's mouth using a tonsil

tip suction

• insert a NG tube to suction out any remaining stomach

contents

• cut the wires to allow the client to expectorate the

emesis

• instruct client to vomit in an emesis basin
• suction the emesis form the client's mouth using a tonsil tip suction

Intermaxillary fixation= wiring of the teeth which are left in lace for around 6 weeks until fracture is healed. Clear vomit can be easily removed from oral cavity by suctioning in the buccal space (b/w gums and teeth)

• attend to client's risk of aspiration first***

INCORRECT:

• wire cutters at hand in case of choking or emesis
• action does not address the client's risk of aspiration