1.
An expected outcome of the cast application that the nurse evaluates is:
Correct Answer
D. Slight edema, soreness, and limitation of range of motion.
Explanation
The nurse evaluates for slight edema, soreness, and limitation of range of motion as an expected outcome of the cast application. This is because the application of a cast can cause some swelling (edema) in the affected area, as well as soreness and a temporary limitation in the range of motion due to immobilization. These symptoms are considered normal and expected after a cast application.
2.
An appropriate technique for the nurse to implement for the client who is being cast is to:
Correct Answer
D. Fold the stockinette or padding over the outer cast edges.
Explanation
When a client is being cast, folding the stockinette or padding over the outer cast edges is an appropriate technique for the nurse to implement. This helps to ensure that the edges of the cast are protected and do not cause any discomfort or irritation to the client. It also helps to secure the stockinette or padding in place and prevents it from slipping or bunching up underneath the cast. By folding the stockinette or padding over the outer cast edges, the nurse is promoting the client's comfort and safety during the casting process.
3.
For cast removal, the nurse correctly instructs the client that:
Correct Answer
B. An enzyme wash may be applied to intact skin.
Explanation
An enzyme wash may be applied to intact skin because it helps to remove any residual adhesive or residue left behind from the cast. This can help to prevent irritation or discomfort when the cast is removed.
4.
A nurse anticipates that the type of traction that will be used for a 32-lb child with a fractured femur is:
Correct Answer
A. Bryant’s traction
Explanation
Bryant's traction is the most appropriate type of traction for a 32-lb child with a fractured femur. This type of traction is commonly used for children under the age of 2 and involves elevating the legs at a 90-degree angle to the body. It is effective in immobilizing the fractured femur and promoting proper alignment and healing. Dunlop's traction is typically used for cervical spine injuries, Weil sling is used for forearm fractures, and Buck's extension traction is used for lower leg fractures.
5.
A nurse anticipates that the type of traction that will be used for an adult client with a fractured humerus is:
Correct Answer
B. Dunlop’s traction
Explanation
Dunlop's traction is the correct answer for an adult client with a fractured humerus. Dunlop's traction is a type of skeletal traction that is commonly used for fractures of the humerus. It involves the use of a halo vest or a sling to support the affected arm and maintain proper alignment of the fractured bone. This type of traction allows for better immobilization and alignment of the fractured bone, promoting healing and preventing further injury.
6.
For a client who is to be placed in Russell’s traction, the nurse prepares the:
Correct Answer
D. Lower extremities
Explanation
The nurse prepares the lower extremities for a client who is to be placed in Russell's traction. Russell's traction is a type of traction used to immobilize and align fractures of the femur or tibia. By applying traction to the lower extremities, the nurse can stabilize the fractured bones and promote proper healing. This involves carefully positioning and securing the client's legs in the traction apparatus, ensuring that the traction is evenly distributed and the client is comfortable.
7.
An appropriate technique for the nurse to implement for a client being placed in traction is to:
Correct Answer
C. Assess the neurovascular status every 1 to 2 hours for the first day.
Explanation
The appropriate technique for the nurse to implement for a client being placed in traction is to assess the neurovascular status every 1 to 2 hours for the first day. This is important to monitor the client's circulation, sensation, and movement in the affected limb. Assessing the neurovascular status helps to identify any potential complications such as impaired blood flow or nerve damage, which can be critical in preventing further injury or complications. Regular assessment allows for prompt intervention if any changes are detected, ensuring the client's safety and well-being.
8.
While in Buck’s extension traction, the client may be positioned as:
Correct Answer
B. On the back, turning to the unaffected side for 10- to 15-minute periods.
Explanation
In Buck's extension traction, the client is positioned on their back and is encouraged to turn to the unaffected side for short periods of time. This position helps to relieve pressure on the affected side and promotes comfort and circulation. It also allows for periodic assessment of the client's skin integrity and overall well-being. This positioning strategy is important to prevent complications such as pressure ulcers and muscle atrophy.
9.
For a client with a fractured femur, a nurse is alert to the possibility of a fat embolus. The nurse specifically watches for:
Correct Answer
B. Restlessness
Explanation
Restlessness is a common sign of a fat embolus in a client with a fractured femur. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress and decreased oxygenation. Restlessness can be an early manifestation of this condition, indicating inadequate oxygenation and increased anxiety. Bradypnea (abnormally slow breathing), bradycardia (abnormally slow heart rate), and hypertension (high blood pressure) are not typically associated with fat embolus and would not be the nurse's primary focus in this situation.
10.
For a client in traction who has skeletal pins, a nurse should:
Correct Answer
B. Apply antiseptic ointment and cover with a split dressing.
Explanation
The correct answer is to apply antiseptic ointment and cover with a split dressing. This is the appropriate action because it helps prevent infection at the pin site. Using povidone-iodine to cleanse the pin site may cause skin irritation and delay healing. Hydrogen peroxide is not recommended as it can damage healthy tissue. Doing both pin sites at the same time with the same swab and solution increases the risk of cross-contamination.