Musculoskeletal

13. The occupational health nurse is teaching a class on the risk factors for developing osteoarthritisoa (OA). Which is a modifiable risk factor for developing OA? 1. Being overweight. 2. Increasing age. 3. Previous joint damage. 4. Genetic susceptibility.

1 1. *Obesity is a well-recognized risk factor for the development of OA and it is modifiable in that the client can lose weight.* 2. Increasing age is a risk factor, but there is nothing the client can do about getting older, except to die. 3. Previous joint damage is a risk factor, but it is not modifiable, which means the client cannot do anything to change it. 4. Genetic susceptibility is a result of family genes, which the client cannot change; it is a nonmodifiable risk factor. TEST-TAKING HINT: The adjective "modifiable" is the key to selecting the correct answer. Only one option "1" contains anything the client has control over changing or modifying.

24. The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? 1. The client with a total knee replacement who is complaining of a cold foot. 2. The client diagnosed with osteoarthritis who is complaining of stiff joints. 3. The client who needs to receive a scheduled intravenous antibiotic. 4. The client diagnosed with back pain who is scheduled for a lumbar myelogram.

1 1. A cold foot on a client who has had surgery may indicate a neurovascular compromise and must be assessed first. 2. A client with osteoarthritis is expected to have stiff joints. 3. A routine medication is not priority over a potential complication of surgery. 4. A routine diagnostic procedure does not have priority over a complication of surgery. TEST-TAKING HINT: The test taker must take a systematic approach when answering prioritizing questions. First, the test taker must determine if any client is experiencing a lifethreatening or life-altering complication such as "loss of limb." The test taker must determine if the sign/symptom is expected for the disease or condition.

46. The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three times a day.

1 1. Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual limb against harder and harder surfaces is done in preparation for prosthesis training. 2. An Ace bandage applied distal to proximal will help decrease edema and help shape the residual limb into a conical shape. 3. Vitamin E oil will help decrease the angriness of the scar, but it will not help with residual limb toughening. 4. Elevating the residual limb will help decrease edema, but it will also cause a contracture if the residual limb is elevated after the first 24 hours. TEST-TAKING HINT: The stem of the question asks the test taker to choose a method of toughening the residual limb. Demonstrating how to apply an elastic bandage or elevating the limb would not accomplish this, so these options could be eliminated from consideration.

20. The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching? 1. Wear supportive tennis shoes with white socks when walking. 2. Carry a complex carbohydrate while exercising. 3. Alternate walking briskly and jogging when exercising. 4. Walk at least 30 minutes three (3) times a week.

1 1. Safety should always be discussed when teaching about exercises. Supportive shoes will prevent shin splints. Colored socks have dye that may cause athlete's foot, which is why white socks are recommended. 2. Clients with diabetes mellitus should carry complex carbohydrates with them. 3. OA occurs most often in weight-bearing joints. Exercise is encouraged, but jogging increases stress on these joints. 4. For exercising to help pain control, the client must walk daily, not three (3) times a week. Walking at least 30 minutes 3 times a week would be appropriate for weight loss. TEST-TAKING HINT: The test taker can rule out "3" as an answer because the stem says pain control; "1" is correct for any exercise program.

42. The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question would be most important for the operating room nurse to ask the client? 1. "Have you made any special arrangements for your amputated limb?" 2. "What types of food would you like to eat while you're in the hospital?" 3. "Would like the rabbi to visit you while you are in the recovery room?" 4. "Will you start checking your other foot at least once a day for cuts?"

1 1. The Jewish faith believes that all body parts must be buried together. Therefore many synagogues will keep amputated limbs until death occurs. 2. Specific foods are important, but not while the client is in the operating room. 3. Spiritual issues are important for the nurse to discuss with the client, but the operating room should be concerned with disposition of the amputated limb. 4. Addressing teaching issues is important, but the most important concern is disposition of the amputated limb. TEST-TAKING HINT: The nurse must always address the cultural needs of the client, and when the test taker sees a specific culture in the stem of a question, it is a prompt that this will be important when selecting the answer.

33. The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis? 1. Take at least 1200 mg of calcium supplements a day. 2. Eat foods low in calcium and high in phosphorus. 3. Osteoporosis does not occur until around age 50 years. 4. Remain as active as possible until the baby is born.

1 1. The National Institutes of Health (NIH) recommend a daily calcium intake of 1200 to 1500 mg per day for adolescents, young adults, and pregnant and lactating women. 2. The pregnant teenager should eat foods high in calcium. 3. Osteoporosis may not occur before age 50 years, but taking calcium throughout the life span will help prevent it. Remember, teenagers tend to focus on the present, not the future, so the most important intervention to teach them is to take calcium supplements. 4. Activity will not help prevent osteoporosis in the teenager; the teenager must take calcium supplements. TEST-TAKING HINT: The age of the client is important when answering questions; developmental stages will help rule out or help select the correct answer.

29. Which foods should the nurse recommend to a client when discussing sources of dietary calcium? 1. Yogurt and dark-green, leafy vegetables. 2. Oranges and citrus fruits. 3. Bananas and dried apricots. 4. Wheat bread and bran.

1 1. The best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and dark-green, leafy vegetables. 2. These foods are high in vitamin C. 3. These foods are high in potassium. 4. These foods are recommended for a high-fiber diet. TEST-TAKING HINT: A question about special diets is a knowledge-based question, and the test taker must know which foods are in which type of diets. Foods high in calcium should be associated with milk products such as yogurt

58. When preparing the nursing care plan for a client with a fractured lower extremity, which would be the most appropriate treatment outcome for the nurse to include? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

1 1. The expected outcome for a client with a fracture is maintaining the function of the extremity. 2. Ambulation with assistance is not the best goal. 3. This is a nursing intervention, not a client goal. 4. Infection is not the highest-priority problem for a client with a fracture. TEST-TAKING HINT: The test taker must note the word "most appropriate" and look at the client as a whole entity. With musculoskeletal problems, maintaining normal function or anatomical function is the desired outcome. Remember that independence is priority for the client.

27. Which signs/symptoms would make the nurse suspect that the client has developed osteoporosis? 1. The client has lost one (1) inch in height. 2. The client has lost 12 pounds in the last year. 3. The client's hands are painful to the touch. 4. The client's serum uric acid level is elevated.

1 1. The loss of height occurs as vertebral bodies collapse. 2. Weight loss is not a sign of osteoporosis. 3. This may indicate rheumatoid arthritis but not osteoporosis. 4. This would be a sign of gout. TEST-TAKING HINT: If the test taker is not sure of the answer and knows that "osteo" means bone, the only answer that is related to bones is the height of the client, the spine.

53. The unlicensed nursing assistant (NA) notifies the nurse of the vital signs of a 28-yearold male client admitted the previous day with a fractured femur. The NA reports a temperature of 101F; pulse 115; respiratory rate 28; copious amounts of thick, white sputum; and "globs" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea, breath sounds, and altered mental status. 2. Draw blood for arterial blood gases and order a portable chest x-ray. 3. Call the health-care provider for an order to administer an antibiotic. 4. Instruct the assistant to encourage the client to deep breathe.

1 1. The nurse should assess the client for signs of hypoxia from a fat embolism. The symptoms listed in this question indicate a fat embolism. Dyspnea, adventitious breath sounds, and confusion indicate hypoxia. Young males are more likely to suffer from a fat embolism, especially from fractured femurs. 2. Arterial blood gases and portable chest x-ray will be done, but they will not be done first. 3. An antibiotic is not the highest-priority medication for this client. Oxygenation is first. 4. Deep breathing is an important intervention in an immobile client, but it is not the first action. The client is unstable. The nurse cannot delegate an unstable client. TEST-TAKING HINT: If the test taker is unsure of the correct answer, always apply the nursing process. Assessment is the first part of the nursing process.

49. The client is taken to the emergency department with an injury to the left arm. Which action should the nurse take first? 1. Assess the nail beds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast.

1 1. The nurse should assess the nail beds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity. 2. Clothing may need to be removed but not before assessment. 3. An x-ray will be done, but is not the highest priority action. 4. A cast may or may not be applied, depending on the type and location of the fracture. TEST-TAKING HINT: When the question asks to prioritize nursing care, usually assessment is first. Assessment is an independent nursing intervention.

30. Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test. 2. Perform non-weight-bearing exercises regularly. 3. Increase the intake of dietary calcium. 4. Refer clients to a smoking cessation program.

1 1. This is an example of a secondary nursing intervention, which includes screening for early detection. 2. The client should perform weight-bearing exercises, which promote osteoblast activity that helps maintain bone strength and integrity. This is a primary nursing intervention. 3. Increasing dietary calcium may be a primary intervention to help prevent osteoporosis or a tertiary intervention, which helps treat osteoporosis. 4. Smoking cessation is a primary intervention, which will help prevent the development of osteoporosis. TEST-TAKING HINT: The nurse must be knowledgeable of primary, secondary, and tertiary nursing interventions. Primary interventions are those that help prevent the disease; secondary interventions are interventions such as screening the client for the disease with the goal of detecting it early; tertiary interventions are interventions implemented when the client has the disease.

39. The 62-year-old client diagnosed with Type 2 diabetes who has a gangrenous right toe is being admitted for a BKA amputation. Which nursing intervention should the nurse implement? 1. Assess the client's nutritional status. 2. Refer the client to an occupational therapist. 3. Determine if the client is allergic to IVP dye. 4. Start a 22-gauge Angiocath in the right arm.

1 1. For wound healing, a balanced diet with adequate protein and vitamins is essential, along with meals appropriate for Type 2 diabetes. 2. An occupational therapist addresses activities of daily living and usually addresses upperextremity amputations. A referral to a physical therapist would be more appropriate to address ambulating and transfer concerns. 3. There is no type of intravenous dye used in this surgical procedure so this question is not appropriate. 4. An 18-gauge catheter should be started because the client is going to surgery; the client may need a blood transfusion, which should be administered through an 18-gauge catheter. TEST-TAKING HINT: The nurse must take into account all the client's comorbid conditions (diabetes Type 2) when selecting the correct answer.

7. The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented? 1. Assess ability to void and log roll every two (2) hours. 2. Medicate with IV steroids and keep the bed in a Trendelenburg position. 3. Place sand bags on each side of the head and give cathartic medications. 4. Administer IV anticoagulants and place on O2 at eight (8) L/min.

1 1.* The lumbar nerves innervate the lower abdomen. The bladder is in the lower abdomen. The client will be required to lie flat, and this is a difficult position for many clients, especially males, to be in to void. Clients are log rolled every 2 hours. *2. The client would be receiving IV pain medication, not steroids. A Trendelenburg position is head down. 3. Sand bags would keep the neck still, but the surgical area is in the lumbar region, so there is no reason the client cannot turn the head; also, cathartic medications are harsh laxatives. 4. The client will be receiving subcutaneous anticoagulant medications to prevent deep vein thromboses, but IV anticoagulant therapy is not warranted. Eight (8) L/min of oxygen is high-flow oxygen that would be used for a client in respiratory distress who does not have carbon dioxide narcosis. TEST-TAKING HINT: The test taker must note the adjective "lumbar"; this can rule out option "3." Knowledge of medication classifications would rule out options "2" and "4."

48. The 32-year old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. 1. Report any pain that is not relieved with analgesics. 2. Eat a well-balanced diet and increase protein intake. 3. Be sure to attend all outpatient rehabilitation appointments. 4. Encourage the client to attend a support group for amputations. 5. Stay at home as much as possible for the first couple of months. Fractures

1, 2, 3, 4 1. Pain not relieved with analgesics could indicate complications or could be phantom pain. 2. A well-balanced diet promotes wound healing, especially a diet high in protein. 3. The client must keep appointments in outpatient rehabilitation to continue to improve physically and emotionally. 4. A support group may help the client adjust to life with an amputation. 5. The client should be encouraged to get out as much as possible and live as normal a life as possible. TEST-TAKING HINT: The test taker needs to select all options that are appropriate. Fractures

65. Which topics should the nurse include in the discharge teaching plan for a client after having a total hip replacement? Select all that apply. 1. Weight-bearing limits. 2. Use of assistive devices. 3. Gradual increase in activity. 4. Medication therapy. 5. Periods of rest.

1, 2, 3, 4 ,5 1. Clients need to understand the amount of weight bearing to prevent injury. 2. Teaching the safe use of assistive devices is necessary prior to discharge. 3. Increases in activity should occur slowly to prevent complications. 4. Using medication therapy, including analgesics, anti-inflammatory agents, or muscle relaxants, should be taught so that client is comfortable while ambulating. 5. The client should be encouraged to rest periodically to promote healing and increase energy. TEST-TAKING HINT: The test taker should apply basic concepts to all surgeries. Many times the test taker may not be familiar with the specific surgery, but by using discharge teaching that is applicable to all clients, a choice can be made.

69. When developing the plan of care for the client having a total knee repair, which of the expected outcomes would the nurse include? Select all that apply. 1. The client has effective pain management. 2. The client does not smoke or use tobacco products. 3. The client ambulates within the weight-bearing limits. 4. The client participates in activities of daily living. 5. The client is able to return to his or her previous lifestyle.

1, 2, 3, 4,5 1. The client needs to have the pain managed so that the client can be as active as possible. This will help avoid complications of immobility. 2. Clients should not be able to smoke after surgery because smoking increases the risk for pulmonary complications. Most hospitals do provide smoking areas outside the building. 3. The client must ambulate within the weight-bearing restrictions so that the knee will not be injured, which may delay healing. 4. All clients should be encouraged to do as much self-care as possible to assist with self-esteem. 5. Not all clients will able to return to their previous life roles and activities but it is the goal. They should be assisted with coping skills so that they will be able to adapt to any changes. TEST-TAKING HINTS: The test taker must select more than one option in these alternate-type questions. Options "1," "2," and "4" are interventions that are applicable to any client having a surgical procedure. Option "3" is the only option that addresses ambulation; therefore, because the client had knee surgery, this would be an appropriate selection for the correct answer.

11. The nurse writes the problem of "pain" for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Assess pain on a 1-10 scale. 2. Administer pain medication PRN. 3. Provide a regular bed pan for elimination. 4. Assess surgical dressing every four (4) hours. 5. Perform a position change by the log roll method every two (2) hours.

1,2 1. *An objective method of quantifying the client's pain should be used.* 2.* Once the nurse has determined that the client is stable and not experiencing complications, the nurse can medicate the client.* 3. A regular bed pan is high and could cause pain for a client diagnosed with back pain. The client should be given a fracture pan. 4. There is no surgical dressing. 5. The client has not been to surgery, so log rolling is not necessary. TEST-TAKING HINT: Two of the options—"4" and "5"—apply to post-surgical cases and could be eliminated.

59. While caring for a client diagnosed with a fracture of the right distal humerus, what data would the nurse assess that would indicate a complication? Select all that apply. 1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 3. Proximal pulses and point tenderness. 4. Coldness of the extremity and crepitus. 5. Palpable radial pulse and functional movement.

1,2,4 1. The nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage. 2. The presence of paresthesia and paralysis indicate impaired circulation. 3. Pulses should be assessed but not proximal to the fracture. Pulses distal to the fracture should be assessed. Point tenderness should be expected. 4. Coldness indicates decreased blood supply. Crepitus indicates air in subcutaneous tissue and is not expected. 5. Palpable radial pulses and functional movement do not indicate a complication has occurred. TEST-TAKING HINT: This is an alternate-type question in which the test taker must select all options that apply. The test taker should remember the neuromuscular assessment, which includes the 6 Ps—pulse, pain, paresthesia, paralysis, pallor, polar (cold).

37. The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement would be the most appropriate statement by the nurse? 1. "This position will help your lungs expand better." 2. "Lying on your stomach will help prevent contractures." 3. "Many times this will help decrease pain in the limb." 4. "The position will take pressure off your backside."

2 1. This position will decrease lung expansion. 2. The prone position will help stretch the hamstring muscle, which will help prevent flexion contractures that may lead to problems when fitting the client for a prosthesis. 3. Lying on the back will not help decrease actual or phantom pain. 4. This will help take pressure off the client's buttocks area, but that is not why it is recommended for a client with a lower-extremity amputation. TEST-TAKING HINT: The test taker can eliminate option "1" if visualizing the client in a prone position. This position will limit expansion of the lung more than increase it. Clients are placed with the head elevated, a position the client in a prone position cannot achieve, when trying to allow for expansion of the lungs.

54. During the morning assessment, the nurse determines that the 80-year-old client admitted with a fractured right femoral neck is confused. Which action should the nurse implement first? 1. Check for a positive Homans' sign. 2. Encourage the client to take deep breaths and cough. 3. Assess the left pedal pulse. 4. Monitor the client's Buck's traction.

2 1. Assessing for a positive Homans' sign is an appropriate intervention, but it is not the best action indicated by the symptoms. 2. Encouraging the client to take deep breaths and cough would aid in the exchange of gases. Mental changes are early signs of hypoxia in the elderly client. 3. The client's right hip is fractured so assessing the left pedal pulse would not be priority. 4. Checking the client's Buck's traction will not address the problem of confusion. TEST-TAKING HINT: The test taker needs to understand what the question is asking. Although the client has a fractured hip, the confusion is the problem. Decreased oxygenation should be the first thought the test taker has when seeing the word "confusion."

3. The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help prevent on-the job-injuries? 1. Increase sodium and potassium in the diet during the winter months. 2. Use the large thigh muscles when lifting and hold the weight near the body. 3. Use soft-cushioned chairs when performing desk duties. 4. Have the employee arrange for assistance with household chores.

2 1. Increased calcium, not potassium or sodium, is helpful in preventing orthopedic injuries. Increasing sodium intake could prevent water loss in a non-air-conditioned warehouse in the summer months, not the winter months. 2. *These are instructions to prevent back injuries as a result of poor body mechanics.* 3. Soft-cushioned chairs are not ergonomically designed. Soft-cushioned chairs promote poor body posture. 4. This might help the client prevent back injuries at home, but it would not prevent job related injuries. TEST-TAKING HINT: The question is asking for information that will prevent on-the-job back injuries. Option "4" can be ruled out because of this. The two (2) electrolytes in option "1" are not associated with orthopedic injuries or bones, thus ruling out this option.

14. The client is diagnosed with osteoarthritis. Which sign/symptom would the nurse expect the client to exhibit? 1. Severe bone deformity. 2. Joint stiffness. 3. Waddling gait. 4. Swan neck fingers

2 1. Severe bone deformity is seen in clients diagnosed with rheumatoid arthritis. 2. *Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 minutes and decreases with movement.* 3. A waddling gait is usually seen in women in their third trimester of pregnancy or in older children with congenital hip dysplasia. 4. Swan neck fingers are seen in clients with rheumatoid arthritis. TEST-TAKING HINT: The test taker can have difficulty distinguishing clinical manifestations of two similar-sounding diseases, osteoarthritis and rheumatoid arthritis. Both diseases involve the joints and cause pain and stiffness. Remember that rheumatoid arthritis can permanently disfigure the client, leading to "bone deformity" and "swan neck fingers."

31. The female client diagnosed with osteoporosis tells the nurse that she is going to perform swim aerobics for 30 minutes every day. Which response would be most appropriate by the nurse? 1. Praise the client for committing to do this activity. 2. Explain that walking 30 minutes a day is a better activity. 3. Encourage the client to swim every other day instead of daily. 4. Discuss that sedentary activities help prevent osteoporosis.

2 1. Swimming is not as beneficial as walking in maintaining bone density because of the lack of weight-bearing activity. 2. Weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weight-bearing exercises promotes bone growth. 3. Swimming is not as beneficial in maintaining bone density because of the lack of weightbearing activity. 4. A sedentary lifestyle is a risk factor for the development of osteoporosis. TEST-TAKING HINT: Sedentary activities include sitting and very low-activity exercises, which are risk factors in developing many diseases and disorders; therefore, option "4" can be eliminated.

43. The client is three (3) hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? 1. Explain to the client that his left leg has been amputated. 2. Medicate the client with a narcotic analgesic immediately. 3. Instruct the client on how to perform biofeedback exercises. 4. Place the client's residual limb in the dependent position.

2 1. The client is three (3) hours postoperative and needs medical intervention. 2. Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, and the nurse needs to medicate the client immediately. 3. Biofeedback exercises will not help address the client's postoperative surgical pain. 4. Placing the residual limb below the heart (dependent) will not help address the client's pain and could actually increase the pain. TEST-TAKING HINT: The test taker needs to be aware of adjectives such as "dependent." The nurse must know medical terms for positioning a client.

71. The nurse is assessing the client who is immediately postoperative from a total knee replacement. Which assessment data would warrant immediate intervention? 1. T 99F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain.

2 1. These vital signs are within normal limits. 2. *Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This can be from immobility or surgery; therefore pain should be assessed on both legs.* 3. Bowel sounds are normally intermittent. 4. This type of pain would make the nurse suspect the client has flatus, which is not a lifethreatening complication and would not warrant immediate intervention. TEST-TAKING HINT: "Warrants immediate intervention" means life threatening, abnormal, or unexpected for the client's condition. Pain with dorsiflexion of the ankle, the Homans' sign, may be life threatening if not treated immediately.

10. The nurse is administering 0730 medications to clients on a medical orthopedic unit. Which medication would be administered first? 1. The daily cardiac glycoside to a client diagnosed with back pain and heart failure. 2. The routine insulin to a client diagnosed with neck strain and Type 1 diabetes. 3. The oral proton pump inhibitor to a client scheduled for a laminectomy this A.M. 4. The fourth dose of IV antibiotic for a client diagnosed with a surgical infection.

2 1. This could be administered after breakfast if necessary. There is nothing in the action of the medication that requires a before-breakfast medication administration. 2.* Clients with Type 1 diabetes are insulin dependent. This medication should be administered before the client eats.* 3. This medication should be held until after surgery. 4. The client has already received three (3) doses of IV antibiotic. This medication could be given after the insulin. TEST-TAKING HINT: The nurse must decide which medication has priority by determining the action of the medication, the route of administration, and the diagnosis of the client.

18. Which client goal would be most appropriate for a client diagnosed with OA? 1. Perform passive range-of-motion exercises. 2. Maintain optimal functional ability. 3. Client will walk three (3) miles every day. 4. Client will join a health club.

2 1. This is an intervention, not a goal, and "passive" means the nurse performs the range of motion, which should not be encouraged. 2. *The two main goals of treatment for OA are pain management and optimizing functional ability of the joints to ensure movement of the joints.* 3. Most clients with OA are elderly, are overweight, and have a sedentary lifestyle so walking three (3) miles every day is not a realistic or safe goal. 4. Joining a gym is an intervention and just because the client joins the gym doesn't mean the client will exercise. TEST-TAKING HINT: The test taker must remember a goal is the measurable outcome of nursing interventions based on the client problem/ diagnosis. Interventions are not goals; therefore the test taker could eliminate "1" and "4" as possible answers.

47. The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement by the rehabilitation nurse indicates the client has accepted the amputation? 1. "I am going to sue the guy that hit my boat." 2. "The therapist is going to help me get retrained for another job." 3. "I decided not to get a prosthesis. I don't think I need it." 4. "My wife is so worried about me and I wish she wouldn't."

2 1. This statement does not indicate acceptance; the client is still in the anger stage of grieving. 2. Looking toward the future and problemsolving indicate that the client is accepting the loss. 3. At this young age, a client with an upperextremity prosthesis needs to be thinking about obtaining employment and living a full life. Getting a prosthesis is important to pursue this goal. 4. This statement does not indicate acceptance; his wife will worry about his life that has been changed dramatically. TEST-TAKING HINT: Always notice when the age is given for the client. This will help guide the test taker to the correct answer.

5. The client with a cervical neck injury as a result of 6. The client diagnosed with cervical neck disc degeneration has undergone a laminectomy. Which interventions should the nurse implement? 1. Position the client prone with the knees slightly elevated. 2. Assess the client for difficulty speaking or breathing. 3. Measure the drainage in the Jackson-Pratt bulb every day. 4. Encourage the client to postpone the use of narcotic medications.

2 1. "Prone" means on the abdomen. On the abdomen with the knees flexed would be an uncomfortable position, placing the spine in an unnatural position. *2. The surgical position of the wound places the client at risk for edema of tissues in the neck. Difficulty speaking or breathing would alert the nurse to a potentially lifethreatening problem.* 3. The drainage from a J-P drain should be emptied and monitored every shift. 4. The client should be kept as comfortable as possible. TEST-TAKING HINT: The nurse must know the meaning of the common medical term "prone" and realize that this would be uncomfortable for the client, thus eliminating option "1." The time frame of "every day" makes option "3" wrong.

44. The nurse is caring for a client with a right below the knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? 1. Notify the client's surgeon immediately. 2. Assess the client's blood pressure and pulse. 3. Reinforce the dressing with additional dressing. 4. Check the client's last hemoglobin and hematocrit level.

2 1. If the client is hemorrhaging, the surgeon would need to be notified, but that has not been determined. 2. Determining if the client is hemorrhaging would be the first intervention. The nurse should check for signs of hypovolemic shock, decreased BP, and increased pulse. 3. Reinforcing the dressing would help decrease bleeding, but the nurse must assess first. 4. Checking client's laboratory results is an appropriate intervention, but it is not the first intervention. TEST-TAKING HINT: Remember that when the stem asks the test taker to identify the first intervention, all four options will be probable interventions but only one is the first intervention. Also, the nurse should always assess first. Remember the nursing process.

21. The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? 1. It will help decrease the inflammation in the joints. 2. It improves tissue function and retards breakdown of cartilage. 3. It is a potent medication that decreases the client's joint pain. 4. It increases the production of synovial fluid in the joint.

2 1. NSAIDs or glucocorticoids help decrease inflammation of the joints. 2. This is the rationale for administering these medications. 3. Narcotic and nonnarcotic analgesics would help decrease the client's pain. 4. There is no medication at this time that helps increase synovial fluid production, but surgery can increase the viscosupplementation in the joint. TEST-TAKING HINT: There are some questions that require the test taker to have the knowledge and there are no Test-Taking Hints to help with selecting the right answer.

2. The 34-year-old male client presents to the outpatient clinic complaining of numbness and pain radiating down the left leg. Which further data would the nurse assess? 1. Posture and gait. 2. Bending and stooping. 3. Leg lifts and arm swing. 4. Waist twists and neck mobility.

2 1. Posture and gait will be affected if the client is experiencing sciatica, pain radiating down a leg resulting from pressure on the sciatic nerve. 2. *The client with pain and numbness would not be able to bend or stoop and should not be asked to do so.* 3. Leg lifts will not give the nurse the needed information and would cause this client pain; also, it is the lower extremity, not the upper extremity, that is being assessed. 4. Waist twists will not assess the mobility of the lower extremity, and neck mobility would be assessed if a cervical neck problem were suspected. TEST-TAKING HINT: Anatomical positioning and the function of spinal nerves would rule out options "3" and "4."

55. The client admitted with a diagnosis of a fractured hip is complaining of severe pain. Which pain management technique would be best for the nurse to implement for this client? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure that the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client to the affected leg using pillows to support the other leg.

2 1. The health-care provider orders the dosage on a PCA. Unless a range of dosages or new order is obtained, a lower dose will not help pain. 2. Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips. 3. Raising the head of the bed or the foot will alter the traction. 4. Turning the client to the affected side would increase pain rather than relieve it. TEST-TAKING HINT: This intervention is a form of assessment, assessing the equipment being used for the client's condition. Remember to apply the nursing process.

72. The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change of shift report? 1. The 84-year-old female with a fractured right femoral neck in Buck's traction. 2. The 64-year-old female who had a left total knee replacement with confusion. 3. The 88-year-old male who had a right total hip replacement with an abduction pillow. 4. The 50-year-old postoperative client who has a continuous passive motion (CPM) device.

2 1. This is a normal treatment of a fractured femoral neck. 2. *This is an abnormal occurrence from this information. This client should be seen first because confusion is a symptom of hypoxia.* 3. This is a common treatment of a total hip replacement. 4. This is a treatment used for total knee replacement. TEST-TAKING HINT: When deciding the answer for this type of question, the test taker who does not know the answer should realize that three (3) choices have normal treatments for the disease process and one (1) option contains different information, such as a symptom, and choose the option that is different.

51. Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus, 0.5 mL intramuscularly, in the deltoid.

2, 5 1. An immobilizer should not be applied snugly. There should be enough room to allow for edema and adequate perfusion of the tissues. 2. Ice packs should be applied ten (10) minutes on and twenty (20) minutes off. This allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. 3. An injured extremity should be elevated above the level of the heart to decrease edema and pain. 4. An x-ray should be done before the immobilizer is in place, not after. 5. Any time trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment. TEST-TAKING HINT: This is an alternative-type question. When selecting all that are correct, it is important to consider the descriptive words that make the options incorrect. Read adjectives and adverbs carefully. The terms "snugly," "dependent," and "after" make options "1," "3," and "4" incorrect.

19. Which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub? 1. Physiatrist. 2. Social worker. 3. Physical therapist. 4. Counselor.

3 1. A physiatrist is a physician who specializes in physical medicine and rehabilitation, but the nurse would not refer the client to this person just because the client is having difficulty with transfers. 2. The social worker does not address this type of physical problem. Social workers address issues concerning finances, placement, and acquiring assistive devices. 3. The physical therapist is able to help the client with transferring, ambulation, and other lower-extremity difficulties. 4. A counselor is not able to help the client learn how to get in and out of the bathtub. TEST-TAKING HINT: The nurse must know the role of all the health-care team members.

62. The client that is one (1) day postoperative total hip replacement complains of hearing a "popping sound" when turning. What assessment data should the nurse report immediately to the surgeon? 1. Dark red-purple discoloration. 2. Equal length of lower extremities. 3. Groin pain in the affected leg. 4. Edema at the incision site.

3 1. Bruising is common after a total hip replacement. 2. When a dislocation occurs, the affected extremity will be shorter. 3. Groin pain or increasing discomfort in the affected leg and the "popping sound" indicate that the leg has dislocated and should be reported immediately to the HCP for a possible closed reduction. 4. Edema at the incision site is common, but an increase in edema or redness should be reported. TEST-TAKING HINT: The nurse should notify the surgeon of abnormal, unexpected, or lifethreatening assessment data; if the test taker did not have an idea of the answer, pain is always a good choice because pain means something is wrong—it may be expected pain, but it may mean a complication.

25. The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor? 1. Calcium deficiency. 2. Tobacco use. 3. Female gender. 4. High alcohol intake.

3 1. Calcium deficiency is a modifiable risk factor, which means the client can do something about this factor—namely, increase the intake of calcium—to help prevent the development of osteoporosis. 2. Smoking is a modifiable risk factor because the client can quit smoking. 3. A nonmodifiable risk factor is a factor that the client cannot do anything to alter or change. Approximately 50% of all women CHAPTER 11 MUSCULOSKELETAL DISORDERS 391 Musculoskeletal will experience an osteoporosis-related fracture in their lifetime. 4. The client can quit drinking alcohol; therefore, this is a modifiable risk factor. TEST-TAKING HINT: The key word to answering this question is "nonmodifiable," which means the client cannot do anything to modify or change behavior that will help prevent developing osteoporosis.

8. The nurse is working with an unlicensed nursing assistant. Which action by the assistant warrants immediate intervention? 1. The assistant feeds a client 2 days postoperative cervical laminectomy a regular diet. 2. The assistant calls for help when turning to the side a client who is post-lumbar laminectomy. 3. The assistant is helping the client who weighs 300 pounds and diagnosed with back pain to the chair. 4. The assistant places the call light within reach of the client who had a disc fusion.

3 1. Clients that are two (2) days postop laminectomy should be eating a regular diet. 2. The client who has undergone a lumbar laminectomy is log rolled. It requires four (4) people or more to log roll a client. 3. *The legs of any client diagnosed with back pain can give out and collapse at any time, but a large client diagnosed with back pain would be at increased risk of injuring the assistant as well as the client. The nurse should intervene before the client or assistant become injured.* 4. This action helps ensures safety for the client. TEST-TAKING HINT: This question is an "except" question. All the options but one contain information that should be done.

15. The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed nursing assistant? 1. Allow the client to stay in bed until the pain becomes bearable. 2. Tell the assistant to give the client a bed bath this morning. 3. Try to encourage the client to get up and go to the shower. 4. Notify the family that the client is refusing to be bathed.

3 1. Clients with OA should be encouraged to move, which will decrease the pain. 2. A bed bath does not require as much movement from the client as getting up and walking to the shower. 3. *Pain will decrease with movement, and warm or hot water will help decrease the pain. The worse thing the client can do is not move.* 4. Notifying the family will not address the client's pain and the client has a right to refuse a bath, but the nursing staff must explain why moving and bathing will help decrease the pain. TEST-TAKING HINT: Allowing clients to stay in bed only increases complications of immobility and will increase the client's pain secondary to OA. Clients with chronic illnesses should be encouraged to be as independent as possible. The family should only be notified if a significant situation has occurred.

70. The nurse is caring for the client who had a total knee replacement (TKR). Which data would the nurse observe to determine if the nursing interventions are effective? 1. The client's lungs have bilateral crackles. 2. The client's knee has flexion of 45 degrees. 3. The client participates in self-care activities. 4. The client has reduced pain using a single approach.

3 1. Effective deep breathing and coughing would be demonstrated by the absence of adventitious sounds. 2. Knee flexion should be at 90 degrees. 3. *Clients should participate in care, in decision- making, and in activities that promote mobility and adaptation to the life changes postoperatively.* 4. Pain relief should involve multiple approaches. TEST-TAKING HINTS: When evaluating interventions, the correct answer should be a desired outcome specific to that client.

60. An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. What intervention should the nurse implement first? 1. Insert an indwelling catheter. 2. Administer a Fleet's enema. 3. Assess abdomen for bowel sounds. 4. Apply Buck's traction. Joint Replacements

3 1. Inserting an indwelling catheter would be a good intervention, but it would not be the first intervention. A tear or injury to the bladder should be suspected. 2. Administering a Fleet's enema should not be implemented until internal bleeding has been ruled out. 3. Assessing the bowel sounds should be the first intervention to determine if an ileus has occurred. This is a common complication of a fractured pelvis. 4. Buck's traction is not used to treat a fractured pelvis. It is used to treat a fractured hip. TEST-TAKING HINT: When prioritizing two equal options, usually assessing is the answer. Joint Replacements

52. When assessing a client with a fractured left tibia and fibula, which data should the nurse report to the health-care provider immediately? 1. Localized edema and discoloration occurring hours after the injury. 2. Generalized weakness and increasing sensitivity to touch. 3. Capillary refill time of nine (9) seconds and increasing pain. 4. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.

3 1. Localized edema and discoloration hours after the injury are normal occurrences after a fracture. 2. Generalized weakness and increasing tenderness are common and not life threatening. 3. The normal capillary refill time (CRT) is less than three (3) seconds. A prolonged refill time and increasing pain indicate circulation impairment. This needs to be reported before compartment syndrome occurs. 4. Pain management is a desired outcome demonstrated by pain relieved after medication administration. TEST-TAKING HINT: The nurse should notify the health-care provider of abnormal or unexpected assessment data; increased capillary refill time indicates a neurovascular complication. All the other options contain normal or expected data.

23. The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests would the nurse expect the health-care provider to order to R/O osteoarthritis? 1. Full body magnetic resonance imaging scan. 2. Serum studies for synovial fluid amount. 3. X-ray of the affected joints. 4. Serum erythrocyte sedimentation rate (ESR).

3 1. MRIs are not routinely ordered for diagnosing OA. 2. There is no serum lab test that measures synovial fluid in the joints. 3. X-rays reveal loss of joint cartilage, which appears as a narrowing of the joint space in clients diagnosed with OA. 4. An ESR is a diagnostic laboratory test for rheumatoid arthritis, not osteoarthritis. TEST-TAKING HINT: If the test taker is guessing which answer is correct and knows that "osteo" means bone, the only option that has any specific connection to bones is an x-ray. This selection would be an educated guess.

28. The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? 1. X-ray of the femur. 2. Serum alkaline phosphatase. 3. Dual-energy x-ray absorptiometry (DEXA). 4. Serum bone Gla-protein test.

3 1. Osteoporotic changes do not occur in the bone until more than 30% of the bone mass has been lost. 2. This serum blood study may be elevated after a fracture, but it does not help diagnose osteoporosis. 3. This test measures bone density in the lumbar spine or hip and is considered to be highly accurate. 4. This test is most useful to evaluate the effects of treatment, rather than as an indicator of the severity of bone disease. TEST-TAKING HINT: The option "2" does not have bone or x-ray in it; therefore, if the test taker did not know the correct answer, eliminating this option would be appropriate. If the test taker knew osteoporosis was secondary to poor absorption of calcium, "3" would be an appropriate selection for the correct answer.

4. The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity would be an example of primary prevention for clients at risk for low back pain? 1. Teach back exercises to workers after returning from an injury. 2. Place signs in the work area about how to perform first aid. 3. Start a weight-reduction group that would meet at lunchtime. 4. Administer a nonnarcotic analgesic to a client complaining of back pain.

3 1. Teaching back exercises to a client who has already experienced a problem is tertiary care. 2. Placing signs with instructions about how to render first aid is a secondary intervention, not primary prevention. *3. Excess weight increases the workload on the vertebrae. Weight-loss activities would help to prevent back injury.* 4. Administering a nonnarcotic analgesic to a client with back pain is an example of secondary or tertiary care, depending on whether the client has a one-time problem or a chronic problem with back pain. TEST-TAKING HINT: Primary care is any activity that prevents an illness or injury.

56. When preparing the discharge teaching for the 12-year-old with a fractured humerus, which information should the nurse include regarding cast care? 1. Keep the arm at heart level. 2. Handle the cast with the tips of the fingers only. 3. Apply an ice pack to any area that itches. 4. Foul smells are expected occurrences. 57. Which statement by the client diagnosed with a fractured ulna would indicate that the nurse needs to do further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

3 1. The arm should be elevated above the heart, not at the level. 2. Handling drying casts with fingertips can create pressure spots that impair circulation and create pressure ulcers. 3. Applying ice packs to the cast will relieve itching and nothing should be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn easily. Alteration in the skin's integrity can become infected. 4. Smells indicate infection and should be reported to the HCP. TEST-TAKING HINT: A concept for any injury is elevating it above the heart to decrease edema. Many times the test taker must apply basic concepts to a variety of client conditions. Any foul smell is not expected in any disease or condition.

38. The recovery room nurse is caring for a client that has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

3 1. The client is in the recovery room, and the dressing must be assessed more frequently than every two (2) hours. 2. The client must come to terms with the amputation; therefore the nurse should encourage the client to look at the residual limb. 3. The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally. 4. The nurse should encourage active, not passive, range-of-motion exercises. TEST-TAKING HINTS: Remember to look at the adjectives that describe the intervention such as "every two (2) hours" and "passive."

50. The nurse is preparing the plan of care for the client with an open fracture of the right arm. Which problem has the highest priority? 1. Anger related to the inability to perform ADLs. 2. Sleep disturbances related to loss of work. 3. Infection related to exposed tissue. 4. Altered body image related to scarring.

3 1. The client may feel anger when unable to perform self-care, but physical problems have a higher priority than psychosocial problems. 2. Sleep disturbances are physical problems but would not be life threatening. 3. The definition of an open fracture is a bone that has penetrated the skin. The highestpriority problem is infection because the skin is the barrier that keeps bacteria from entering the surrounding tissue. 4. Body image is a psychosocial problem that has a lower ranking than physical problems. TEST-TAKING HINT: Physiological problems always have priority when the problem is applicable to the condition. Anger, sleep, and body image would not have priority over an infection.

35. The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement? 1. Encourage the client to take Tums with at least eight (8) ounces of water. 2. Teach the client to take Tums with the breakfast meal only. 3. Instruct the client to take Tums 30 to 60 minutes before a meal. 4. Discuss the need to get a monthly serum calcium level.

3 1. There is no reason to take Tums with eight (8) ounces of water. Tums are usually chewed. 2. Tums should not be taken with meals. 3. Free hydrochloric acid is needed for calcium absorption; therefore Tums should be taken on an empty stomach. 4. To determine the effectives of calcium supplements the client must have a bone density test, not a serum calcium level measurement. TEST-TAKING HINT: If unsure of the answer, the test taker should not select an option that has an absolute-type word such as "only," "always," or "never." There are very few absolutes in health care.

64. When assessing the wound of a client who had a total hip replacement, the nurse finds small, fluid-filled lesions on the right side of the dressing. What explanation is the most probable rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy.

3 1. These are not burns from the cautery unit. Such burns would be located in or near the incision site and are usually black. 2. These are not caused by herpes simplex, the lesions of which occur in a linear pattern along a dermatome. 3. Fluid-filled blisters are from a reaction to the tape and usually occur along the edge of the tape. 4. Skin reactions to latex are local irritations or generalized dermatitis, not blisters. TEST-TAKING HINT: If the test taker does not know the answer, the test taker might think about the dressing because the lesions are on the side of the dressing. How is a dressing anchored to the skin? Answer: with tape. The test taker would choose the option that has the word "tape."

5. The client with a cervical neck injury as a result of a motor-vehicle injury is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control would be an independent nursing action? 1. Medicate the client with a muscle relaxant. 2. Heat alternating with ice applied by a physical therapist. 3. Watch television or listen to music. 4. Discuss surgical options with the health-care provider.

3 1. This is an example of collaborative care. 2. This is an example of collaborative care. *3. This is distraction and is an alternative method often recommended for the promotion of client comfort.* 4. Surgery is collaborative care. TEST-TAKING HINT: The question asks for an alternative type of care. Options "1," "2," and "4" are all collaborative care. If the test taker can find a common thread among three of the options, then the correct answer will be the other option.

40. The male nurse is helping his friend cut wood with an electric saw. His friend cut two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the neighbor to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the neighbor's house and call 911.

3 1. Wrapping the hand with towels would be appropriate, but it is not the first intervention. 2. Holding the arm above the head will help decrease the bleeding, but it is not the first intervention. 3. Applying direct pressure to the artery above the amputated parts will help decrease the bleeding immediately and is the first intervention the nurse should implement. Then the nurse should instruct the client to hold the hand above the head, apply towels, and call 911. 4. Calling 911 should be done, but it is not the first intervention. TEST-TAKING HINT: Remember that when the stem asks the test taker to identify the first intervention, all four options will be probable interventions, but only one is the first intervention.

22. The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA? 1. "I take medication every two (2) hours for my pain." 2. "I use a heating pad when I go to bed at night." 3. "I wear a copper bracelet to help with my OA." 4. "I always wear my ankle splints when I sleep."

3 1. Medication is a standard therapy and is not considered an alternative therapy. 2. A heating pad is an accepted medical recommendation for the treatment of pain for clients with OA. 3. Alternative forms of treatment have not been proved efficacious in the treatment of a disease. The nurse should be nonjudgmental and open to discussions about alternative treatment, unless it interferes with the medical regimen. 4. Conservative treatment measures for OA include splints and braces to support inflamed joints. TEST-TAKING HINTS: The test taker needs to read the stem carefully to be able to determine what the question is asking; there is only one option with alternative-type treatment, which is option "3"; options "1," "2," and "4" these are accepted treatment options that would be listed in a textbook.

9. The nurse is caring for clients on an orthopedic floor. Which client should be assessed first? 1. The client diagnosed with back pain who is complaining of a "4" on a 1-10 scale. 2. The client who has undergone a myelogram who is complaining of a slight headache. 3. The client 2 days postop disc fusion that has a T 100.4, P 96, R 24, and BP 138/78. 4. The client diagnosed with back pain who is being discharged and whose ride is here.

3 1. Mild back pain is expected with this client. 2. Lumbar myelograms require access into the spinal column. A small amount of cerebrospinal fluid may be lost, causing a mild headache. The client should stay flat in bed to prevent this from occurring. 3. *This client is postop and now has a fever. This client should be assessed and the health-care provider should be notified.* 4. A discharged client does not have priority over a surgical infection. TEST-TAKING HINT: Options "1" and "2" contain assessment data that are expected for the procedure.

12. The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse? 1. Continue working until the shift is over and then try to sleep on a heating pad. 2. Go immediately to the emergency department for treatment and muscle relaxants. 3. Inform the charge nurse and nurse manager on duty and document the occurrence. 4. See a private health-care provider on the nurse's off time but charge the hospital.

3 1. The nurse should not continue working, and this is self-diagnosing and treating. 2. The nurse may go to the emergency department, but this is not the first action. 3. *The first action is to notify the charge nurse so that a replacement can be arranged to take over care of the clients. The nurse should notify the nurse manager or house supervisor. An occurrence report should be completed documenting the situation. This provides the nurse with the required documentation to begin a worker's compensation case for payment of medical bills.* 4. The nurse has the right to see a private healthcare provider in most states, but this is not the first action. TEST-TAKING HINT: When the test taker is determining a priority, then all of the answers may be appropriate interventions, but only one is implemented first. The test taker should read the full stem, identifying the important words and making sure that he or she understands what the question is asking.

45. The nurse is caring for clients on a surgical unit. Which nursing task would be most appropriate for the nurse to delegate to an unlicensed nursing assistant? 1. Help the client with a 2-day postop amputation put on the prosthesis. 2. Request the assistant double-check a unit of blood that is being hung. 3. Change the surgical dressing on the client with a Syme amputation. 4. Ask the assistant to take the client to the physical therapy department.

4 1. A client who is only two (2) days postop amputation would not be putting on a prosthesis. 2. Two (2) registered nurses must double-check a unit of blood prior to infusing the blood. 3. The surgical dressing is changed by the surgeon or the nurse; Syme amputation is above the ankle, just removing the foot. 4. The nursing assistant could take a client to another department in the hospital. TEST-TAKING HINT: Remember teaching, assessing, and evaluating cannot be delegated.

63. The nurse is preparing the client who received a total hip replacement for discharge. Which statement would indicate that further teaching is needed? 1. "I should not cross my legs because my hip may come out of the socket." 2. "I will call my HCP if I have a sudden increase in pain." 3. "I will sit on a chair with arms and a firm seat." 4. "After three (3) weeks, I don't have to worry about infection."

4 1. Clients should not cross their legs because the position increases the risk for dislocation. 2. If the client experiences a sudden increase in pain, redness, edema, or stiffness in the joint or surrounding area, the client should notify the HCP. 3. Clients should sleep on firm mattresses and sit on chairs with firm seats and high arms. These will decrease the risk of dislocating the hip joint. 4. Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection. TEST-TAKING HINT: Note the stem is asking about the need for "further teaching." This means the test taker is looking for an option that is not expected. This is an "except" question. Sometimes if the test taker will change the question and say "the client understands the teaching," then the option that is incorrect is the answer.

67. When assessing the client six (6) hours after having a right total knee replacement, which data should the nurse report to the surgeon? 1. A total of 100 mL of red drainage in the autotransfusion drainage system. 2. Pain relief after using the patient-controlled analgesia (PCA) pump. 3. Cool toes, distal pulses palpable, and pale nail beds bilaterally. 4. Urinary output of 60 mL of clear yellow urine in three (3) hours.

4 1. Drainage in the first 24 hours can be expected to be 200-400 mL. When using an autotransfusion drainage system, the client's blood will be filtered and returned to the client. 2. Pain relief with the PCA does not require notifying the surgeon. 3. Coolness of toes is concerning but because there were other indicators of adequate circulation, the HCP should not be notified. Circulation is not restricted if pulses are present. Seeing pale pink indicates blood loss during surgery. 4. *The urinary output is not adequate; therefore the surgeon needs to be notified. This is only 20 mL per hour. The minimum should be 30 mL per hour.* TEST-TAKING HINT: A concept that the test taker will see throughout testing and throughout the nurse's practice is that 30 mL of urine output per hour is necessary. Remember this indicates that the kidneys are being adequately perfused and that the heart is pumping effectively.

16. The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem would the nurse identify? 1. Severe pain. 2. Body-image disturbance. 3. Knowledge deficit 4. Depression.

4 1. Pain is a physiological problem, not a psychosocial problem. 2. A client with OA does not have bone deformities; therefore body-image disturbance would not be appropriate. 3. After seven (7) years of OA and multiple treatment modalities, knowledge deficit would not be appropriate for this client. 4. *The client experiencing chronic pain often experiences depression and hopelessness.* TEST-TAKING HINT: The adjective "psychosocial" should help the test taker rule out option "1." The test taker needs to read the stem carefully. This client has had a problem for years and therefore "3" could be ruled out as a correct answer.

41. A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action would preserve the thumb so that it could possibly be reattached in surgery? 1. Place the right thumb directly on some ice. 2. Put the right thumb in a glass of warm water. 3. Wrap the thumb in a clean piece of material. 4. Secure the thumb in a plastic bag and place on ice.

4 1. Placing the amputated part directly on ice will cause vasoconstriction and necrosis of viable tissue. 2. Warm water will cause the amputated part to disintegrate and lose viable tissue. 3. Wrapping the amputated part in a piece of material will not help preserve the thumb so that it can be reconnected. 4. *Placing the thumb in a plastic bag will protect it and then placing the plastic bag on ice will help preserve the thumb so that it may be reconnected in surgery. Do not place the amputated part directly on ice because this will cause necrosis of viable tissue.* TEST-TAKING HINT: Make sure the test taker knows what the question is asking before selecting the option. The question is asking "what will help preserve the thumb?"—that is the key to answering this question.

61. The nurse is preparing the preoperative client for a total hip replacement (THR). Which information should the nurse include concerning postoperative care? 1. Keep abduction pillow in place between legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees.

4 1. The abduction pillow should be kept between the legs while in bed to maintain a neutral position and prevent internal rotation. 2. The client should deep breathe and cough at least every two (2) hours to prevent atelectasis and pneumonia. 3. The client will need to turn every two (2) hours but should not turn to the affected side. 4. Using a high-seated toilet and chair will help prevent dislocation by limiting the flexion to less than 90 degrees. TEST-TAKING HINT: Option "1" has the word "all"; an absolute word such as this usually eliminates the option as a possible correct answer. Nursing usually does not have situations that have absolutes.

34. The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? 1. Keep the bed in the high position. 2. Perform passive range-of-motion exercises. 3. Turn the client every two (2) hours. 4. Provide nighttime lights in the room.

4 1. The bed should be kept in the low position. Preventing falls is a priority for a client diagnosed with osteoporosis. 2. Range-of-motion exercises will help prevent deep vein thrombosis or contractures, but they do not help prevent osteoporosis. 3. Turning the client will help prevent pressure ulcers, but that does not help prevent osteoporosis. 4. Nighttime lights will help prevent the client from falling; fractures are the number-one complication of osteoporosis. TEST-TAKING HINT: The test taker should realize that the bed should be kept in a low position at all times and should eliminate this as a possible answer; ROM exercises and turning will help prevent complications of immobility, not osteoporosis.

68. When preparing the client for the transition to home rehabilitation after having a total knee replacement, which information regarding discharge teaching would the nurse include? 1. Deep breathe and cough every two (2) hours. 2. Procedure for emptying Jackson-Pratt drainage. 3. Burning or frequency of urination is expected. 4. Modify the home for altered mobility.

4 1. The client should continue to perform respiratory exercises such as incentive spirometry and deep breathing and coughing, but this is not needed every two (2) hours. 2. The client will not be discharged with a J-P drain; it will be removed prior to discharge. 3. Any client who experiences the symptoms of urinary tract infection should report these to the health-care provider. 4. *Modification of the home is essential to the rehabilitation of the client using assistive devices for ambulation. The postoperative goals for this client are to maximize mobility and promote health.* TEST-TAKING HINT: The nurse should always think about safety; therefore the test taker should select options that address safety issues. Note that option "1" is doing an intervention every two (2) hours and that would not be appropriate for discharge.

66. The nurse is preparing a plan of care for the client who has had a total hip replacement. Which outcome would be most appropriate for this client? 1. The client has limited amount of pain relief. 2. The client will have limited ability to ambulate. 3. The client will have hip instability for several months. 4. The client will have adequate hip joint motion.

4 1. The expected outcome for the client who has had a total hip replacement should be pain free or almost pain free. 2. The client should be able to ambulate with almost full mobility. 3. The hip joint should be stable. 4. The hip should have functional motion. TEST-TAKING HINT: With musculoskeletal problems functional movement is priority. Also note that options "1" and "2" have the word "limited" and "3" has "instability," all of which are negative outcomes, so the test taker could eliminate these options.

26. The client diagnosed with osteoporosis asks the nurse, "Why does smoking cigarettes cause my bones to be brittle?" Which response by the nurse would be most appropriate? 1. "Smoking causes nutritional deficiencies that contribute to osteoporosis." 2. "Tobacco causes an increase in blood supply to the bones, causing osteoporosis." 3. "Smoking low-tar cigarettes will not cause your bones to become brittle." 4. "Nicotine impairs the absorption of calcium, causing decreased bone strength."

4 1. This would be the rationale for heavy alcohol use leading to the development of osteoporosis. 2. Smoking decreases, not increases, blood supply to the bone. 3. Cigarette smoking has long been identified as a risk factor for osteoporosis, and it doesn't matter if it is low tar. 4. Nicotine slows the production of osteoblasts and impairs the absorption of calcium, contributing to decreased bone density. TEST-TAKING HINT: The test taker must always be aware of the words "increase" and "decrease" when selecting a correct answer.

1. The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-L5. Which scientific rationale explains the incidence of a ruptured disc in the elderly? 1. The client did not use good body mechanics when lifting an object. 2. There is an increased blood supply to the back as the body ages. 3. Older clients develop atherosclerotic joint disease as a result of fat deposits. 4. Clients develop intervertebral disc degeneration as they age.

4 1. Back pain occurs in 80% to 90% of the population at different times in their lives. Although not using good body mechanics when lifting an object may be a reason for younger clients to develop a herniated disc, it is not the reason that most elderly people develop back pain. 2. There is a decreased blood supply as the body ages. 3. Older clients develop degenerative joint disease. Fat does not deposit itself in the nucleus pulposus. *4. Less blood supply, degeneration of the disc, and arthritis are reasons elderly people develop back problems.* TEST-TAKING HINT: The clue in this question is "elderly." The answer must address a problem that would occur as a result of aging.

32. The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data would indicate an adverse effect of the medication? 1. The client complains of nausea and vomiting. 2. The client is drinking two (2) glasses of milk a day. 3. The client has a runny nose and nasal itching. 4. The client has had numerous episodes of nosebleeds.

4 1. Nausea and vomiting may occur during initial stages of therapy, but they will disappear as treatment continues. 2. The client should be sure to consume adequate 392 MED-SURG SUCCESS Musculoskeletal amounts of calcium and vitamin D while taking calcitonin. 3. Rhinitis, runny nose, is the most common side effect with calcitonin nasal spray along with itching, sores, and other nasal symptoms. 4. Nosebleeds are adverse effects and should be reported to the client's HCP. TEST-TAKING HINT: If the test taker has no idea of the answer, an appropriate option to select would be an option that has bleeding in it; bleeding is abnormal and would indicate an adverse effect.

57. Which statement by the client diagnosed with a fractured ulna would indicate that the nurse needs to do further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

4 1. Protein is necessary for healing. 2. By wiggling the fingers of the affected arm, the client can improve the circulation. 3. Pain medication should be taken prior to perception of severe pain. Pain relief will require more medication if allowed to become severe. 4. The immobilizer should be kept on at all times. This indicates that the client does not understand the teaching and needs the nurse to provide more instruction. TEST-TAKING HINT: When selecting an answer for questions like this, the test taker should remember to look for an untrue statement. This indicates that teaching is needed.

17. The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client? 1. Take the medication on an empty stomach. 2. Make sure the client tapers the medication when discontinuing. 3. Apply the medication topically over the affected joints. 4. Notify the health-care provider if vomiting blood.

4 1. This medication should be taken with food to prevent gastrointestinal distress. 2. Glucocorticoids, not NSAIDs, must be tapered when discontinuing. 3. Topical analgesics are applied to the skin; NSAIDs are oral or intravenous medications. 4. *NSAIDs are well known for causing gastric upset and increasing the risk for peptic ulcer disease, which could cause the client to vomit blood.* TEST-TAKING HINT: The worse scenario option is "4," which has blood in the answer. If the test taker did not know the answer, then selecting an option with blood in it would be most appropriate.

36. The client must take three (3) grams of calcium supplement a day. The medication comes in 500 mg/tablets. How many tablets will the client need to take daily?_______

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