H.K. is taken to surgery for open reduction and internal fixation (ORIF) of the tibia and fibula fractures. He
returns with a full-leg fiberglass cast with windows over the areas of surgery.
Describe the assessment of a patient with a long leg cast involving trauma and surgery.
What will be an ideal response?
• The five Ps should be assessed, paying special attention to capillary refill, temperature, color,
movement, and sensation of toes.
• Assess tightness of cast at edges because continued swelling might result in tightening of the cast
and compartment syndrome.
• Assess for increasing or excessive pain because these might indicate infection or ischemia.
• Assess drainage on the cast by drawing a line around edges of drainage at regular intervals.
• Although fiberglass casts allow for better ventilation than plaster casts, a cast still covers large
areas of skin. Assess odor of cast. Foul odor may indicate infection.
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The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infant's inner mid thighs and the fingers on the outside of the infant's hips,
touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: a. Positive Allis test. b. Negative Allis test. c. Positive Ortolani sign. d. Negative Ortolani sign.
An 18-year-old woman at 18 weeks' gestation is being seen in the prenatal clinic. Her weight gain is 25 pounds over her prepregnant weight. Which is the perinatal nurse's best approach to care at this visit?
A. Ask the patient to complete a 3-day dietary recall while she is in the clinic. B. Explain the possible concerns related to excessive weight gain in pregnancy C. Explain to the patient that weight gain is not a concern in pregnancy. D. Teach the patient about the expected normal weight gain during pregnancy.
The patient informs the hospice nurse, "I'm not sold on this hospice thing. I'm not looking for Jesus, I'm just dying." What would be the most therapeutic response by the nurse?
a. "Spiritualism is as you define it." b. "Rejecting the spiritual aspect of yourself may not be in your best interest." c. "Hospice service is about how to make your remaining time meaningful." d. "Based on what you say, hospice service may not answer your needs."
The nurse performing a backrub should begin at the:
a. shoulder. b. base of the neck. c. sacral area. d. lumbar area.