Author: Anonymous

When caring for a client with a fracture of the ulna and radius, what assessment finding will the nurse report immediately to the health care provider?

Case Study Question 6 The nurse is caring for a 23-year-old client admitted to the medical-surgical unit following surgery for a compound fracture of the right tibia and fibula. Nurses’ Notes   0830: Admitted from Post Anesthesia Care Unit following surgery to repair an open fracture with internal fixation with application of a fiberglass cast. R lower extremity elevated. IV infusing as ordered. Client medicated for pain prior to transport. Vital Signs BP 110/72, HR 90, RR 29, Temp 99F (37.2C). Unable to assess pedal pulse on R lower extremity due to cast. Motion of toes limited by pain and cast. Will monitor for signs of acute complications. 0930: Client resting at this time. Will continue to monitor. 1100: Client reporting pain 10/10 in R lower extremity. Updated neurovascular checks. 1115: Vital Signs BP 82/44, HR 112, RR 22, Temp 99F (37.2C). Provider notified of client changes 1145: Cast removed at bedside, see updated flow sheet. 1245: Vital Signs BP 116/70, HR 88, RR 16, Temp 98.8 F(37.1C), pain 3/10.   Neurovascular Flowsheet   Right Lower Extremity Pain Score  0-10/10 Motion F = full L = limited N = none Sensation F = full P = partial N = none Capillary Refill B = brisk < 3 seconds S = sluggish > 3 seconds Color N = normal P = pale D = dusky C = cyanotic Warmth H = hot W = warm T = tepid C = cold   Pulse 4+ bounding 3+ increased 2+ normal 1+ weak 0 absent UTA unable to assess     Time:  0830 3/10 L F B N W UTA 0930 3/10 L F B N W UTA 1030 4/10 L F B N W UTA 1100 10/10 N N S P T UTA 1115 10/10 N N S P T UTA 1130 10/10 N N S D T UTA 1145 10/10 L N S P T 1+ 1245 3/10 L N S N C 0 Orders   0830: Admission Orders: Bedrest with right leg elevated on 2 pillows May use bedside commode with assistance, no weight bearing to R lower extremity Advance to Regular diet as tolerated VS and neurovascular checks every hour for 4 hours then every 4 hours. 1130: STAT Orders: Strict bedrest, maintain R leg at level of the heart Assist client to use bedpan; Monitor intake and output Keep client nothing by mouth until cleared Document height and weight Order cast cutting tray and compartment pressure measuring device to bedside Check Neurovascular status and vital signs every 15 minutes for 2 hours  IV fluid bolus of 500 mL of normal saline over 30 minutes for blood pressure

The nurse notes that the client has developed a hematoma at the hip replacement surgical site with a decreased pedal pulse of the same leg.  What is the most appropriate nursing action for this client?

After receiving change of shift report which patient will the nurse assess first?

The image below represents what type of fracture?  

The nurse on the orthopedic unit is going to lunch and is conducting a “hand-off” communication to the charge nurse. The goal of “hand-off” communication is to do which of the following?

The client has suffered an ankle sprain and the nurse is preparing the client for discharge. Which plan is appropriate for the nurse to teach the client? 

After teaching a group of clients with osteoarthritis about the benefits of regular exercise, which of the following statements indicate that teaching has been effective?

In the care of a client in the first 24 hours of a below the knee amputation (BKA), what is the nurse’s priority intervention?

The RN is caring for a client with carpal tunnel syndrome who has been admitted for surgery. Which intervention will the RN delegate to the Unlicensed Assistive Personnel (UAP)? Select all that apply.