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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Shane, 12 years old, is an avid fan of skateboarding. She tried to learn the moves, but accidentally fell on her first try. Agonizing in pain, she was then brought to the Emergency Department. The X-ray film showed an incomplete fracture of the left tibia. The doctor ordered for a closed reduction and a cast was applied on her left leg. Which of the following is an incorrect intervention for Shane?
  1. Elevate entire extremity higher than the client’s heart for the first 24 to 48 hours
  2. Exercise her toes
  3. Support Shane’s foot with the ankle in 90 degrees of flexion
  4. Create a turning schedule for position changes every 3 hours
Explanation
Answer - D - Creating a turning schedule every 3 hours for position changes is the incorrect intervention. Position changes should be scheduled every 2 hours to prevent the complications of immobility which are pneumonia, skin breakdown, or deep vein thrombosis. The rest of the choices are correct nursing actions for a client with closed reduction.
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