Nclex-PN Musculoskeletal

The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate? 1. Document the findings. 2. Place the leg in a flat position. 3. Check the client's blood pressure. 4. Immediately notify the registered nurse.

1 (Rationale: Following total hip replacement, the hip incision may have a wound-suction drain in place, which is expected to drain usually less than 50 mL every 8 hours. The nurse should document the findings. The nurse may check the client's blood pressure, but this action is not directly related to the amount of drainage from the device. There is no need to notify the registered nurse immediately, although this information may need to be conveyed to the registered nurse at the end of the work shift. Placing the leg flat in bed should be done only if prescribed by the primary health care provider. Additionally, this action is unrelated to the subject of the question.)

An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the primary health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the *priority* relates to addressing which client problem? 1. Risk for constipation 2. Impaired tissue integrity 3. Risk for activity intolerance 4. Disturbed thought processes

1 (Rationale: Risk for constipation is the priority problem for this client. Although all of these problems may apply to this client, lying supine, being older, and having cognitive impairment places the client at extreme risk for constipation and possibly impaction. The client likely does have disturbed thought processes because of the Alzheimer's disease and impaired tissue integrity because of the fracture. Because activity is restricted, activity tolerance is unknown.)

The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which *highest priority* assessment? 1. Calf pain 2. Heel breakdown 3. Bladder distention 4. Extremity shortening

1 (Rationale: The highest priority assessment that the nurse needs to monitor in this client is the presence of calf pain. Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Calf pain is a sign of this complication. Although bladder distention may occur postoperatively, this assessment is incorrect because it is not specific to the information in the question. Extremity lengthening or shortening may occur as a result of knee replacement but is not the highest priority. Additionally, heel breakdown is not the highest priority.)

The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? *Select all that apply.* 1. Older clients 2. Obese people 3. Client with liver disease 4. Postmenopausal women 5. Clients from poor economic communities 6. Clients with cardiovascular health problems

1,2,4,6 (Rationale: Hyperuricemia and gout are often seen in older clients with cardiovascular health problems, obese people, and postmenopausal women. Secondary gout affects people of all ages. Disorders such as multiple myeloma and certain carcinomas result in increased production of uric acid because of a greater turnover of cellular nucleic acids. Treatment involves management of the underlying disorder. The incidence of gout is increasing as the baby boomer generation reaches 65 years of age. The risk of acquiring secondary gout is not related to clients with liver disease or those people from poor economic communities.)

The nurse is caring for a client recently diagnosed with Parkinson disease (PD). The nurse is assessing the client and knows that PD is characterized by what cardinal signs/symptoms? *Select all that apply.* 1. Tremor 2. Dry skin 3. Muscle rigidity 4. Postural instability 5. Orthostatic hypertension 6. Bradykinesia or akinesia (slow movement/no movement)

1,3,4,6 (Rationale: The four cardinal signs/symptoms of Parkinson's disease (PD) are tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability. In addition to changes in voluntary movement, many clients experience autonomic nervous system symptoms, such as excessive perspiration, not dry skin, and orthostatic hypotension, not hypertension. Orthostatic hypotension is likely related to loss of sympathetic innervation in the heart and blood vessel response. PD is a progressive neurodegenerative disease that is the one of the most common neurologic disorders of older adults.)

The nurse is reinforcing instructions to the client with a below-the-knee amputation (BKA) with regard to measures to protect the residual limb. The nurse would be sure to include which point in discussions with the client? 1. Put a clean nylon sock on the residual limb daily. 2. Use a mirror to inspect all areas of the residual limb. 3. Toughen the skin of the residual limb by rubbing it with alcohol. 4. Apply lotion daily to prevent cracking of the skin of the residual limb.

2 (Rationale: The client would use a mirror to visualize all areas of the residual limb after BKA. This will be most effective in helping the client detect any areas of redness or breakdown early. The client would not apply oils, creams, or lotions because they soften the skin too much for safe prosthesis use. The client would wear a clean woolen (not nylon) sock on the residual limb each day. The client would avoid using alcohol because it could cause drying or cracking of the skin.)

A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge? 1. Two-point gait 2. Three-point gait 3. Swing-through gait 4. Four-point alternate gait

2 (Rationale: The nurse teaches the client the three-point gait of crutch walking. The client with a new fracture that is casted with a plaster cast needs to avoid weight bearing. The three-point gait identifies a gait that allows non-weight bearing on the affected extremity. The client should not bear weight on the affected extremity until the primary health care provider evaluates the client on the follow-up examination.)

The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain? 1. Anorexia 2. Weakness 3. Weight loss 4. Hypertension

2 (Rationale: Uncontrolled musculoskeletal pain can result in harmful effects, resulting in certain assessment findings, such as weakness, fatigue, and immobility. Anorexia is associated with the gastrointestinal system; weight loss is associated with the endocrine system; and hypertension is associated with the cardiovascular system in terms of uncontrolled pain.)

The nurse is caring for a client diagnosed with Paget's disease. What abnormal laboratory values would the nurse specifically monitor in a client with Paget's disease? *Select all that apply.* 1. Decreased potassium 2. Elevated serum calcium 3. Elevated serum amylase 4. Increased creatine kinase (CK-MM) 5. Elevated serum alkaline phosphatase (ALP) 6. Elevated 24-hour urinary hydroxyproline level

2, 5, 6 (Rationale: The laboratory values the nurse would expect to note in the client with Paget's disease of the bone include an elevated serum calcium, an elevated 24-hour urinary hydroxyproline level, and an elevated serum alkaline phosphatase (ALP). Increases in ALP and urinary hydroxyproline levels along with calcium are the primary laboratory findings indicating possible Paget's disease. Disorders of bone and the parathyroid gland are often reflected in an alteration of the serum calcium or phosphorus level. Therefore these electrolytes, especially calcium, are monitored. ALP can be further evaluated by alkaline phosphatase isoenzymes. Serum isoenzyme levels of bone ALP are used to monitor effectiveness of treatment. A 24-hour urinary hydroxyproline level reflects bone collagen turnover and indicates the degree of disease severity. The higher the hydroxyproline, the more severe is the disease. Decreased serum potassium, increased CK-MM level, and elevated amylase level are not related to Paget's disease.)

The nurse is caring for a recently admitted client with painful muscle spasms due to a traumatic injury. Besides drug therapy, what are some of the physical measures the nurse expects will be prescribed for this client? *Select all that apply.* 1. Limiting fluids 2. Whirlpool baths 3. Physical therapy 4. Muscle relaxants 5. Application of hot compresses 6. Immobilization of the affected muscle

2,3,6 (Rationale: Muscle spasm is defined as involuntary contraction of a muscle or muscle group. Some physical measures employed to treat muscle spasms related to a traumatic injury include immobilization of the affected muscle; application of cold, not hot, compresses; whirlpool baths; and physical therapy. Limiting fluids can increase the incidence of muscle spasms. Muscle relaxants are a form of drug therapy.)

A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? 1. "There is no reason to be concerned. I have seen lots of these procedures." 2. "Skeletal traction is much more effective than skin traction in your situation." 3. "You have concerns about skeletal versus skin traction for your type of fracture?" 4. "Your fracture is very unstable. You will die if you don't have this surgery performed."

3 (Rationale: Asking the client if there are concerns about skeletal versus skin traction identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Telling the client the fracture is unstable and you will die if you don't have this surgery, identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. Also, saying that skeletal traction is more effective than skin traction is offering a false reassurance, and this type of response will block communication. In addition, saying that there is no reason to be concerned is also a communication block and reflects a lack of the client's right to an opinion.)

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1. Footboards 2. Large pillows 3. Small pillows 4. Soft mattress

3 (Rationale: Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.)

Which intervention should be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? 1. Monitor vital signs every 4 hours. 2. Administer oral analgesics as needed. 3. Place the left arm in a dependent position for 24 hours. 4. Monitor the site for swelling, bleeding, and hematoma formation.

3 (Rationale: The biopsy site would be elevated for 24 hours to reduce edema, not placed in a dependent position. Other aspects of care include monitoring the site for swelling, bleeding, and hematoma formation; monitoring vital signs; and administering analgesics for site discomfort.)

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown? 1. Left heel 2. Scapulae 3. Right heel 4. Back of the head

3 (Rationale: The client's right heel is at high risk for pressure and breakdown. There are specific areas that are under pressure and are at risk for breakdown in the client who has skeletal traction. These include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.)

The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? 1. Fish 2. Turkey 3. Cheese 4. Sweet potatoes

3 (Rationale: The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are available and recommended for those with typically low calcium intake.)

A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse should monitor the client closely for pain and provide the client with which instruction? 1. "I will be bringing your pain medication at 10:00 pm." 2. "You will not feel pain because of the spinal anesthesia." 3. "You will need to let me know when you start to get feeling back in your legs." 4. "You will not be able to take pain medication until you have been up to the bathroom."

3 (Rationale: The nurse should tell the client to "let me know when you start to get feeling back in your legs". Analgesics need to be encouraged in the postoperative client as needed. The nurse explains that the client will start to feel sensation as the spinal anesthetic wears off. Along with the increased sensation, the client will also experience pain. Although saying pain might not be felt because of the spinal anesthesia may be correct information, it does not address the issue of pain assessment. Telling the client that you will bring the pain medication at 10:00 pm is not appropriate, because the nurse does not schedule the pain medication administration. Also, telling the client you will not be able to take pain medication until you have been up to the bathroom is incorrect because the client should be medicated before any activity is attempted, especially in the postoperative period. Also, following this type of surgery, the client should be using a fracture bedpan and should not be up to the bathroom.)

A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? 1. Check the blood pressure. 2. Check the pin sites for drainage. 3. Check the neurovascular status of the affected extremity. 4. Monitor the client's ability to perform active range of motion to the affected extremity.

3 (Rationale: The nurse would check the neurovascular status and assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Bone fragments and tissue edema associated with a fracture can cause nerve damage. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active range of motion to an extremity that is fractured and in traction.)

A client has just had skeletal traction applied following insertion of pins. The nurse should place *highest priority* on performing which action? 1. Performing pin site care 2. Explaining to the client the upcoming pin care procedure 3. Ensuring that the weights on the traction setup are hanging free 4. Providing for diversion such as watching television or reading a newspaper

3 (Rationale: When a client has skeletal traction, the highest priority is to assess the traction setup. The nurse must ensure that the weights on the traction setup are hanging free. If the weights are resting on or against any support, the purpose of the traction is defeated. The other actions are components of care.)

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? 1. Pain 2. Hemorrhage 3. Edema of the stump 4. Separation of wound edges

4 (Rationale: Clients with diabetes mellitus are at greater risk of wound infection and separation of wound edges leading to delayed wound healing. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.)

The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction? 1. Resume regular full activity the following day. 2. Do not eat or drink anything until the following morning. 3. Keep the shoulder completely immobilized for the rest of the day. 4. Report to the registered nurse the development of fever or redness and heat at the site.

4 (Rationale: Following arthroscopy, signs/symptoms of infection such as fever or inflammation (redness or heat) should be reported to the registered nurse who will perform an assessment and contact the primary health care provider. The client may resume the usual diet immediately. The arm does not have to be immobilized completely once sensation has returned, but the client usually is encouraged to refrain from strenuous activity for at least a few days.)

A primary health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy? 1. Decrease fluid intake. 2. Decrease dietary fiber. 3. Chew the tablet thoroughly. 4. Take the medication following a meal.

4 (Rationale: Iron preparations can be very irritating to the stomach and, to eliminate this problem from occurring, are best taken after a meal. They may also be taken 1 hour before a meal or between meals to enhance absorption. Primary health care provider preference will determine when the client would take the medication. The tablet is swallowed whole, not chewed. Because the client may experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy.)

The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client? 1. "You will never be able to do tai chi again!" 2. "Tai chi is good for you, so you can start any time." 3. "Tai chi uses only your leg muscles, so it would be all right." 4. "You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the primary health care provider."

4 (Rationale: Tai chi is a slow, relaxed, and graceful series of movements. In tai chi, each movement flows into the next one and the entire body is always in motion, with the movements performed gently and at uniform speed. The upper arms often are held in a horizontal fashion. Clients who have had shoulder repair (rotator cuff repair) will not be able to lift the affected arm to perform the movements. Doing so can undo the surgical repair and cause the client severe pain. The client may be able to resume tai chi at some point in the future when permitted by the primary health care provider.)

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which complication? 1. Fat embolism 2. Venous thrombosis 3. Volkmann's thrombosis 4. Compartment syndrome

4 (Rationale: The client's signs/symptoms are indicative of compartment syndrome. In this situation, the edema and the cast are compressing the structures within the leg. As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. The primary health care provider needs to be notified as soon as possible. Fat embolism may result from a fracture, but the client is not experiencing any signs/symptoms of this complication. Venous thrombosis may occur after fractures but would not affect sensation. Volkmann's contracture is a result of compartment syndrome in an upper extremity following a fractured humerus)

A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved? 1. Resting the joint 2. Applying moist heat 3. Elevation of the joint 4. Active intermittent range of motion

4 (Rationale: The least likely helpful measure for the client with acute exacerbation of bursitis is active intermittent range of motion. Local measures that help relieve bursitis (inflammation of a bursa) include joint rest, elevation, and the application of heat. Exercise is not helpful during the acute stage. In addition, nonsteroidal anti-inflammatory agents, analgesics, and short-term systemic corticosteroids may be prescribed.)

The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a *need for further teaching*? 1. "I should elevate my arm to reduce the swelling." 2. "I should use a sling to limit movement and keep my arm elevated." 3. "I should return to the primary health care provider in about 10 days to have the sutures removed." 4. "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."

4 (Rationale: There is a need for further teaching when the client says, "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery." Postoperatively, depending on the type of surgical procedure, the client will have a bulky dressing in place for 4 to 7 days. The affected arm is elevated to reduce swelling. A sling is useful to limit movements and to keep the arm elevated. The sutures are removed in about 10 days after surgery. Within 2 to 3 weeks postoperatively, the client will begin physical therapy, with exercises to promote full range of motion of the wrist and prevent adhesion formation in the carpal tunnel.)

The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the *need for further teaching*? 1. "I need to report bleeding gums or tarry stools." 2. "I need to report fever, redness, or increased pain." 3. "I need to tell my other doctors about the metal implant." 4. "I don't need to be worried if the shape of my knee changes."

4 (Rationale: There is a need for further teaching when the client states that there is no need to worry if the shape of the knee changes. After TKR, the client would report signs/symptoms of infection or any changes in the shape of the knee, which could indicate developing complications. With a metal implant, the client requires anticoagulant therapy and would know to report adverse effects of this therapy, such as bleeding. The client would tell all caregivers about the metal implant because certain diagnostic tests will need to be avoided, and antibiotic prophylaxis will be needed before invasive procedures.)

A client has just had an application of a nonplaster cast. What are some of the synthetic materials used for nonplaster casts? *Select all that apply.* 1. Rayon 2. Nylon 3. Neoprene 4. Fiberglass 5. Polyester-cotton knit

4,5 (Rationale: Synthetic materials for casts are much more common and include fiberglass and polyester-cotton knit. These materials are lighter than plaster and require minimal drying time. Some primary health care providers may use synthetic casts for upper extremities and plaster-of-Paris casts for lower extremities because plaster casts can bear more weight for a longer time. However, newer synthetic materials are stronger than earlier ones. Synthetic casts can be bivalved as needed. Rayon is the oldest manufactured fiber produced and is used in a variety of textile applications including shirts and skirts. Nylon is also a synthetic fiber that was produced to replace silk. Neoprene is a synthetic rubber used frequently for weather resistance, padding, gasket seals, and insulation purposes as well as a fabric for a scuba diving suit. Rayon, nylon and neoprene are not materials used for nonplaster casts.)

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? 1. "I need to avoid getting the cast wet." 2. "I will use my fingertips to lift and move the leg." 3. "I need to cover the casted leg with warm blankets." 4. "I can use a padded coat hanger end to scratch under the cast."

1 (Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching.)

The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1. Elevating the limb and applying ice to the affected leg 2. Elevating the limb and covering it with bath blankets 3. Keeping the leg horizontal and applying ice to the affected leg 4. Placing the leg in a slightly dependent position and applying ice

1 (Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect.)

The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding? 1. An oral temperature of 101° F orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep breathing exercises

1 (Rationale: For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs/symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101° F or higher should be reported because it might indicate infection or require that the hardware be removed.)

The nurse is caring for a client with a tibial fracture who was just diagnosed with acute compartment syndrome (ACS). Which procedure does the nurse anticipate the surgeon will perform? 1. Fasciotomy 2. Arteriotomy 3. Venous thromboectomy 4. External compartment removal

1 (Rationale: If ACS is verified, the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure and restores circulation to the affected area. Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Arteriotomy is a surgical opening into an artery. A venous thromboectomy is removal of a piece of clot or embolus from a vein. It is indicated in clients with deep vein thrombosis (DVT) whose symptoms are severe and present for fewer than 7 days. External compartment removal is not a surgical procedure.)

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1. Pork 2. Seafood 3. Sardines 4. Plain yogurt

1 (Rationale: Of the items listed, pork would contain the least amount of calcium.)

A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement? 1. Administer an analgesic. 2. Immobilize the knee temporarily. 3. Notify the primary health care provider immediately. 4. Put the client's knee through full passive range of motion.

1 (Rationale: Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed.)

The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action? 1. Stay with the victim. 2. Assist the victim out of the automobile. 3. Leave the victim to call an ambulance. 4. Tell the victim to keep moving the leg to maintain circulation.

1 (Rationale: The appropriate nursing action is to stay with the victim. Because the victim complains of severe leg pain, a fracture should be suspected. With a suspected fracture the victim is not moved unless it is dangerous to remain in that spot. While staying with the victim the nurse should have someone else call for emergency help. Before moving the client, the site of fracture is immobilized to prevent further injury. Moving the leg can cause further injury to the victim's leg.)

A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane? 1. Left hand, and 6 inches lateral to the left foot 2. Right hand, and 6 inches lateral to the right foot 3. Left hand, placing the cane in front of the left foot 4. Right hand, placing the cane in front of the right foot

1 (Rationale: The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.)

A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. Based on these findings the nurse should take which action? 1. Notify the registered nurse. 2. Reassess the client in 30 minutes. 3. Check to see whether it is time for more pain medication. 4. Encourage the client to continue with active range-of-motion exercises to the left arm.

1 (Rationale: The client with early acute compartment syndrome typically complains of severe, diffuse pain that is unrelieved with pain medication. The nurse notifies the registered nurse, who contacts the primary health care provider immediately. The other actions are inaccurate interventions.)

The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 1. Anesthesia consent 2. Consent for the procedure 3. Administration of an analgesic 4. Explanation of the procedure to the client

1 (Rationale: The item that is least likely needed before reduction of a fracture in the casting room is an anesthesia consent. Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room.)

The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? 1. "I will use a raised toilet seat." 2. "I will bend carefully to put on socks and shoes." 3. "I will sit in chairs without arms for better mobility." 4. "I will exercise the leg past the point of 90-degree flexion."

1 (Rationale: The postoperative hip surgery client understands the material presented when the client plans to use a raised toilet seat. It is important for clients with an insertion of a femoral head prosthesis to use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion.)

The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs/symptoms of fat embolism. The nurse provides appropriate care by performing which action? 1. Monitoring for signs of dyspnea 2. Monitoring the client's temperature regularly 3. Maintaining external rotation of the right leg 4. Educating the client to report paresthesia of the right lower leg

1 (Rationale: The signs/symptoms of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. The sign of maintaining external rotation of the right leg is indicative of the hip fracture itself. Monitoring the temperature regularly indicates signs of infection, and telling the client to report paresthesia of the right leg indicates signs of severe circulatory impairment.)

The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a *need for further teaching*? 1. "Crutch tips will not slip, even when wet." 2. "Use of someone else's crutches is a bad idea." 3. "Crutch tips should be inspected periodically for wear." 4. "I need to have spare crutches and tips available."

1 (Rationale: There is a need for further teaching when the client says that crutch tips won't slip even when wet. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed)

The nurse is assisting in caring for a client who has sustained a nasal fracture. The nurse monitors for which *priority* finding specifically related to this injury?

1 (Rationale: When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture.)

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? *Select all that apply.* 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft-padded object that will fit under the cast to scratch the skin under the cast.

1, 2, 3 (Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The PHCP is notified immediately if circulatory impairment occurs.)

The nurse is caring for a client who was just admitted with a diagnosis of fractured right femur. What are some of the acute complications the nurse needs to assess for? *Select all that apply.* 1. Crush syndrome 2. Ischemic necrosis 3. Fat embolism syndrome 4. Arterial thromboembolism 5. Acute compartment syndrome (ACS) 6. Hemorrhage and hypovolemic shock

1, 3, 5, 6 (Rationale: The nurse monitors the client for acute complications of fractures such as crush syndrome, fat embolism syndrome (FES), acute compartment syndrome (ACS), and hemorrhagic and hypovolemic shock. Infection is also another acute complication of fractures. Venous and not arterial thromboembolism is also an acute complication that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). Ischemic necrosis is a chronic complication. Clinical manifestations of beginning complications must be treated early to prevent serious consequences.)

The nurse is caring for a client with osteoporosis who is being discharged with instructions to take calcium with vitamin D. Which instructions should the nurse give the client about taking this medication? *Select all that apply.* 1. "Take a third of the daily dose at bedtime." 2. "Increase fluid intake, unless medically contraindicated." 3. "Take the medication with 6 to 8 ounces of water to help dissolve it." 4. "You will need to have your blood tested for calcium every month." 5. "You can get a slight fever with this medication, so check your temperature every day." 6. "After taking this medication for 6 months, you won't have to worry about having any more fractures."

1,2,3 (Rationale: The nurse needs to tell the client to take a third of the daily dose at bedtime because no weight-bearing activity to build bone occurs while sleeping. Fluids should be increased and the medication should be taken with 6 to 8 ounces of water.)

An elderly client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? *Select all that apply.* 1. Osteoporosis 2. Foot disorders 3. Bony metastases 4. Carpal tunnel syndrome 5. Diminished visual acuity 6. Changes in cardiac function

1,2,3,6 (Rationale: Disease processes like osteoporosis, foot disorders, bony metastases, and changes in cardiac function increase the older adults' risk for hip fracture. A history of carpal tunnel syndrome does not affect the elderly client's risk for hip fracture. Diminished visual acuity is a sensory, physiological change that can occur in the older adult and is not a disease process. Test-Taking Strategy(ies): Knowledge of the subject, hip fractures in the elderly will help in choosing the correct options. Eliminate carpal tunnel syndrome first because this condition is related to the hands and does not increase one's risk for falls. Also, diminished visual acuity is a normal sensory change related to aging. The other disease processes are correct.)

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? *Select all that apply*. 1. Femur 2. Skull 3. Tibia 4. Sternum 5. Shoulder 6. Vertebrae

1,2,3,6 (Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur.)

The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? *Select all that apply.* 1. Drink plenty of fluids. 2. Avoid taking diuretics. 3. Avoid taking acetaminophen. 4. Organ meats are allowed on your diet. 5. Avoid excessive physical or emotional stress.

1,2,5 (Rationale: The nurse needs to teach the client to drink plenty of fluids to prevent the formation of urinary stones. Increasing fluid intake helps dilute urine and prevent sediment formation. The client also needs to avoid taking diuretics because this would limit the amount of fluid in the body and would not help prevent sediment formation. Excessive physical or emotional stress can also exacerbate the disease. The nurse needs to teach the client stress-management techniques to help prevent future attacks of gout. A strict low-purine diet is recommended and clients should avoid foods such as organ meats, shellfish, and oily fish with bones (e.g., sardines). Excessive alcohol intake and fatty meats should also be avoided. The nurse needs to also teach the client to determine which foods precipitate acute attacks and try to avoid them. In addition to food and beverage restrictions, clients with gout should avoid all forms of aspirin and diuretics because they may precipitate an attack. Acetaminophen does not have to be avoided.)

The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? *Select all that apply.* 1. Ensure that the machine is well padded. 2. Assess the client's response to the machine. 3. When the machine is not in use, store it on the floor. 4. Check the cycle and range-of-motion settings once a day. 5. Turn off the machine while the client is having a meal in bed. 6. Make sure that the joint being moved is properly positioned on the machine.

1,2,5,6 (Rationale: While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach.)

The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? 1. The brace should be applied directly next to the skin. 2. The device is applied before getting out of bed in the morning. 3. The Velcro closures should be fairly loose to avoid constriction. 4. Areas of skin redness at the edges of the brace indicate a good, snug fit.

2 (Rationale: A back brace or TLSO is individually fitted to the client. The brace is applied in the morning before getting out of bed. The brace should not irritate the skin with proper fitting. The closures should be secure but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin.)

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus? 1. Minimal dyspnea 2. Clear chest x-ray 3. Oxygen saturation 85% 4. Arterial oxygen level of 78 mm Hg

2 (Rationale: A clear chest x-ray is a favorable indicator that the fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea (unlabored breathing), not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.)

The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take *first*? 1. Provide pin care. 2. Check the client's alignment in bed. 3. Medicate the client with an analgesic. 4. Call the primary health care provider (PHCP).

2 (Rationale: A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described.)

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2 (Rationale: A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.)

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? 1. Crutches and then both legs simultaneously 2. Crutches and the right leg, then advance the left leg 3. Crutches and the left leg, then advance the right leg 4. Left leg and right crutch, then right leg and left crutch

2 (Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait. Putting the crutches and the right leg down, then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then right leg and left crutch down describes a two-point gait.)

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 1. The cast will be bivalved. 2. A window will be cut in the cast. 3. The cast will be replaced with an air splint. 4. Extra padding will be put over this area of the cast.

2 (Rationale: A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking x-rays, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated.)

A client with possible rib fracture has never had a chest x-ray. The nurse should tell the client which statement about the procedure? 1. "The x-ray stimulates a small amount of pain." 2. "It is necessary to remove jewelry and any other metal objects." 3. "The client will be asked to breathe in and out during the x-ray." 4. "The x-ray technologist will stand next to the client during the x-ray."

2 (Rationale: An x-ray is a photographic image of a part of the body on a special film that is used to diagnose a wide variety of conditions. The x-ray itself is painless. Any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area.)

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head

2 (Rationale: Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.)

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted? 1. Intact skin surfaces 2. Bowel movement every 5 days 3. Equal calf measurements bilaterally 4. Active range of motion (ROM) of uninvolved joints

2 (Rationale: Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (measurable by equal calf measurements and absence of pain or redness in the calf area), active baseline ROM to uninvolved joints, intact skin, and a bowel movement every other day.)

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 1. Trochanter roll to prevent abduction while turning 2. Pillow to keep the right leg abducted during turning 3. Pillow to keep the right leg adducted during turning 4. Trochanter roll to prevent external rotation while turning

2 (Rationale: Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client.)

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which action to maintain client safety after this procedure? 1. Keeping the head of bed flat 2. Having the client use an overhead trapeze 3. Having the client use a logrolling technique for repositioning 4. Placing pillows under the length of the legs

2 (Rationale: Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.)

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze

2 (Rationale: Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning.)

The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? 1. Contact the primary health care provider. 2. Petal the cast edges with adhesive tape. 3. Massage the skin at the edges of the cast. 4. Place a small face cloth in the cast around the edges of the cast

2 (Rationale: If a client with a cast has skin irritation from the edges of the cast, the appropriate intervention by the nurse would be to petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the primary health care provider.)

A client is complaining of low back pain with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? 1. Applying heat 2. Bending or lifting 3. Taking ibuprofen 4. Maintaining bed rest

2 (Rationale: Low back pain with radiation into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing, or lifting the leg straight up while supine (straight leg raise test). The other actions assist in alleviating pain.)

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? 1. "It is a normal response and indicates the presence of phantom limb pain." 2. "It is a normal response and indicates the presence of phantom limb sensation." 3. "It is an abnormal response and indicates that the client is in denial about the limb loss." 4. "It is an abnormal response and indicates that the client needs more psychological support."

2 (Rationale: Phantom limb sensations felt in the area of the amputated limb indicate a normal response. These can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, called "phantom limb pain." The origin of the pain is less well understood, but the client should also be prepared for this whenever possible.)

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches out to the side of the right foot

2 (Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support, while the stronger side swings through.)

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 1. 3 inches to the front and side of the client's toes 2. 8 inches to the front and side of the client's toes 3. 15 inches to the front and side of the client's toes 4. 20 inches to the front and side of the client's toes

2 (Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from *6 to 10 inches* in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance.)

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? 1. The client holds the walker using the handgrips. 2. The client advances the walker with reciprocal motion. 3. The client leans forward slightly when advancing the walker. 4. The client supports body weight on the hands while advancing the weaker leg.

2 (Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.)

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? 1. Administer an analgesic. 2. Notify the registered nurse. 3. Check the circulation again in 30 minutes. 4. Provide range-of-motion exercises to the fingers of the left hand.

2 (Rationale: The client with pallor, slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. Regardless of the cause, the LPN notifies the registered nurse immediately, who will contact the primary health care provider. These signs can occur with constriction from a tight cast as well. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area.)

The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which *early* symptom of compartment syndrome? 1. Cold, bluish fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is relieved only by an opioid analgesic

2 (Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.)

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? 1. Massaging the skin at the rim of the cast 2. Petaling the cast edges with adhesive tape 3. Using a rough file to smooth the cast edges 4. Applying lotion to the skin at the rim of the cast

2 (Rationale: The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast.)

During admission data collection the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area? 1. Sensation and reflexes 2. Balance and coordination 3. Bowel and bladder control 4. Muscle strength and flexibility

2 (Rationale: The nurse is testing cerebellar function, specifically ataxia to evaluate the client's balance and coordination. Examples of disorders that include interferences in this area could be Parkinson's disease, multiple sclerosis, or brain attack (stroke). This test does not identify the problems addressed in any of the other options.)

A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? 1. Provide pin care. 2. Notify the registered nurse. 3. Remove some of the traction weights. 4. Find out when the next dose of the prescribed analgesic can be given.

2 (Rationale: The nurse realigns the client, and, if ineffective, then notifies the registered nurse, who then calls the primary health care provider (PHCP). A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse never removes traction weights unless specifically prescribed by the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described.)

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse should be *most* useful in trying to provide good skin care to the client? 1. Having another nurse tilt the client to the side 2. Asking the client to pull up on a trapeze to lift the hips off the bed 3. Pushing down on the mattress of the bed while administering care 4. Asking the client to lift up by digging into the mattress with the unaffected leg

2 (Rationale: The nursing action that would be most useful if the client in skeletal traction may not turn from side to side is to have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other.)

The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 1. "Use a sling on the left arm." 2. "Lift the left arm up over the head." 3. "Lift the right arm up over the head." 4. "Make a fist with the hand of the casted arm."

2 (Rationale: The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.)

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that *further instructions are needed* about skin care if the client makes which statement? 1. "I will soak the skin and then wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if it will be directly exposed to the sun."

2 (Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid direct exposure of the skin to the sunlight.)

The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the *early* manifestations of this syndrome? *Select all that apply.* 1. Fever 2. Dyspnea 3. Petechiae 4. Hypoxemia 5. Tachypnea 6. Decreased level of consciousness

2, 4, 5 (Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop.)

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a *need for further teaching*? 1. "I will avoid excessive amounts of alcohol." 2. "I'm glad I can still drink as much coffee as I want." 3. "I must make sure I include fruits and vegetables in my daily diet." 4. "I need to make sure I have adequate amounts of calcium and vitamin D."

2 (Rationale: There is a need for further teaching when a client with osteoporosis says "I'm glad I can still drink as much coffee as I want." The nurse needs to teach clients to avoid excessive alcohol and caffeine consumption and about the need for adequate amounts of calcium and vitamin D for bone remodeling. The nutritional considerations for the treatment of a client with a diagnosis of osteoporosis are the same as those for preventing the disease. The nurse needs to help the client develop a nutritional plan that is most beneficial in maintaining bone health. The plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine.)

The nurse is teaching a client about crutch walking. Which comment by the client indicates a *need for further teaching*? 1. "I know I need strong arm muscles to walk with crutches." 2. "My crutches must rest up underneath my arm for extra support." 3. "I need to make sure that there are rubber tips on the ends of my crutches so I won't slip." 4. "I'm going to use the three-point gait, because it allows little weight bearing on my affected leg."

2 (Rationale: There is a need for further teaching when the client states that crutches need to rest up underneath the arm. Crutches must not rest underneath the client's arm, because it could cause injury to the nerves of the brachial plexus. Crutches must be measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body.)

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? 1. Heat 2. Cold 3. Analgesics 4. Prescribed intermittent traction

2 (Rationale: Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the client with a vertebral fracture. The use of cold is incorrect because ice is applied to a site for only the first 24 hours after an injury. Application of ice to the spine of a client could be uncomfortable, increase spasms, and result in feeling chilled.)

The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the *early* signs of this complication by checking which criteria? *Select all that apply.* 1. The client's renal system 2. The client's mental status 3. The client's mobility status 4. The client's respiratory function 5. The client's cardiovascular system

2, 4 (Rationale: The earliest signs/symptoms of fat embolism include changes in the client's mental status or signs/symptoms of impaired respiratory function caused by impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment are likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs/symptoms of fat embolism.)

The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? *Select all that apply.* 1. Apply the bandage in a top-down manner. 2. Use a shrinker stocking or sock to cover the wrapped stump. 3. Rewrap the residual limb once a day with an elastic bandage. 4. Begin residual limb care when sutures or staples are removed. 5. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. 6. When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown.

2, 4, 5, 6 (Rationale: After the sutures or staples are removed, the client begins residual limb care. The home care nurse tells the client and family that they can use a shrinker stocking or sock to cover the wrapped stump because it is easier to apply. The limb also needs to be inspected every day for signs of inflammation or skin breakdown. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. The limb should be rewrapped 3 times a day and not once a day with an elastic bandage. The elastic bandage should be applied in a figure-eight manner and never wrapped in a top-down manner.)

The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? *Select all that apply.* 1. Psoriasis 2. Bony deformity 3. Limited joint mobility 4. Peripheral neuropathy 5. Peripheral vascular disease 6. History of skin ulcers or previous amputation

2,3,4,5,6 (Rationale: Certain conditions place clients with diabetes at increased risk for amputation. These factors include peripheral neuropathy, limited joint mobility, bony deformity, peripheral vascular disease, and a history of skin ulcers or previous amputation. The nurse needs to observe for changes that indicate peripheral neuropathy or vascular insufficiency.)

The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? *Select all that apply.* 1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living.

2,4,5 (Rationale: The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend his/her hips beyond 90 degrees and not 120 degrees, doesn't sit or stand for long periods of time, and doesn't cross his/her legs past the midline of the body. The nurse should ensure that the client engages in walking and mild, not rigorous, exercise to maintain strength and that the client uses assistive/adaptive devices when performing activities of daily living.)

The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which issues could place the client at increased risk for disturbed thought processes? Select all that apply. 1. Relatives at the bedside 2. Stress from the fracture 3. Eyeglasses left at home 4. Unfamiliar hospital setting 5. Side effects of medications 6. Hearing aid available and in working order

2,6,4,5 (Rationale: Confusion in the older client with hip fracture could result from the eyeglasses being left at home, an unfamiliar hospital setting, stress from the fracture, side effects of medications, concurrent systemic diseases, or cerebral ischemia. Relatives at the bedside would help the client's functional level, and hearing aids enhance the client's interaction with the environment and can reduce disorientation.)

The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the primary health care provider's (PHCP) prescriptions and notes that the PHCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. 1. A 2. B 3. C 4. D

3

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1. A bone fragment has injured the nerve supply in the area. 2. An injured artery causes impaired arterial perfusion through the compartment. 3. Bleeding and swelling cause increased pressure in an area that cannot expand. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

3 (Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment triggering the signs/symptoms.)

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take *next*? 1. Provide pin care. 2. Medicate the client. 3. Notify the registered nurse. 4. Remove 2 pounds of weight from the traction.

3 (Rationale: A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client and if ineffective, would next notify the registered nurse, who will then contact the primary health care provider. Severe leg pain once traction has been established indicates a problem. Medicating the client would be done after trying to determine and treat the cause. The nurse would never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described.)

The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast? 1. A long leg cast 2. A short leg cast 3. A hip spica cast 4. A body jacket cast

3 (Rationale: A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included it is called a single hip spica. If two are included it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.)

The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 1. Elevating the limb for 24 hours 2. Monitoring vital signs every 4 hours 3. Administering intramuscular opioid analgesics 4. Monitoring the site for swelling, bleeding, hematoma

3 (Rationale: Administering intramuscular opioid analgesics to a client following a bone biopsy is an unnecessary action for the nurse. Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.)

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1. Giving pin care once a shift 2. Massaging the skin of the right leg with lotion every 8 hours 3. Inspecting the skin on the right leg at least once every 8 hours 4. Releasing the weights on the right leg for range-of-motion exercises daily

3 (Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the primary health care provider. Skin traction does not involve pin care.)

The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which finding does the nurse identify as *early* signs/symptoms of possible fat embolism? 1. Decreased heart rate and increased restlessness 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Increased heart rate and increased oxygen saturation

3 (Rationale: Early signs/symptoms of possible fat embolism are increased heart rate and adventitious breath sounds. Fat embolism commonly causes signs/symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The other findings are incorrect.)

A client is treated in the primary health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 1. Resting the foot 2. Applying an Ace wrap 3. Applying a heating pad 4. Elevating the ankle on a pillow while sitting or lying down

3 (Rationale: Heat is not used in the first 24 hours after a sprained ankle because it could increase venous congestion, which would increase edema and pain. Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time.)

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The newness of the fracture

3 (Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.)

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3 (Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The PHCP should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.)

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 1. Feelings of isolation 2. Inability to tolerate activity 3. Concerns about body image 4. Inability to physically move about

3 (Rationale: The client is expressing concerns about body image. The data in the question are unrelated to isolation and inability to tolerate activity. Although the client is unable to physically move about, this is not associated with what the client is upset about.)

The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client *needs further teaching* if the client makes which statement about the casting? 1. The cast will give off heat as it dries. 2. The cast edges may be trimmed with a cast knife. 3. The client may bear weight on the cast in 30 minutes. 4. A stockinette will be placed over the leg area to be casted.

3 (Rationale: The client needs further teaching about plaster casts if the client plans to bear weight on the cast in 30 minutes. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries.)

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? 1. Dry, sterile dressings 2. Hydrocolloid dressings 3. Moist, sterile saline dressings 4. Half-strength povidone-iodine dressings

3 (Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. The other types of wound care are incorrect.)

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be *most* concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites

3 (Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.)

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student *needs further teaching* if the student states that which is an associated risk factor? 1. Postmenopausal age 2. Family history of osteoporosis 3. High-calcium diet consumption 4. Long-term use of corticosteroids

3 (Rationale: The nursing student needs further teaching if the student states that a high-calcium diet is an associated risk factor of osteoporosis. Risk factors associated with osteoporosis include a diet that is deficient in calcium. Postmenopausal age, family history, and long-term use of corticosteroids are risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide.)

A client with a herniated inter-vertebral lumbar disk complains of a knife-like, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason? 1. Pressure on the spinal cord 2. Pressure on the spinal nerve root 3. Muscle spasm in the area of the herniated disk 4. Excess cerebrospinal fluid production in the area

3 (Rationale: The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The other interpretations of the pain are incorrect.)

A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

3 (Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. Option 1 places undue pressure on the client's unaffected foot. Option 2 is not used for the purpose of countertraction. Buck's extension traction is applied to the leg, so you can eliminate option 4.)

Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a *need for further teaching*? 1. "I should elevate my knee while sitting." 2. "I should avoid excessive use of the joint for several days." 3. "I can apply heat to my knee if it becomes uncomfortable." 4. "I should return to the primary health care provider in about 7 days for follow-up."

3 (Rationale: There is a need for further teaching when the client says that heat is applied to the affected joint for pain and swelling. Ice needs to be applied, not heat. Also, analgesics are administered as prescribed. The client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return to the primary health care provider for follow-up in about 7 days.)

The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client? 1. Gentle regular exercise 2. A warm bath or shower early in the day 3. Increasingly vigorous and high-impact exercise 4. An individualized program of pain medication administration

3 (Rationale: Vigorous or high-impact exercise could be damaging to articulating surfaces within joints and should be avoided by clients with osteoarthritis. The other actions may be helpful in promoting joint mobility.)

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the *priority*? 1. Take a set of vital signs. 2. Call the radiology department. 3. Immobilize the leg before moving the client. 4. Reassure the client that everything will be fine.

3 (Rationale: When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.)

The nurse is teaching a client how to walk with a cane. Which information should the nurse include? *Select all that apply.* 1. The cane is placed on the affected side. 2. A quad-cane provides a narrower base for the cane. 3. The cane should create no more than 30 degrees of flexion of the elbow. 4. The top of the cane should be parallel to the greater trochanter of the femur. 5. A straight leg cane is used if the client only needs minimal support for an affected leg.

3, 4, 5 (Rationale: The cane should create no more than 30 degrees of flexion of the elbow, and the top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist. A straight leg cane is sometimes used if the client needs only minimal support for an affected leg. A hemi-cane or quad-cane provides a broader, not narrower, base for the cane and therefore more support. The cane is placed on the unaffected side and not the affected side.)

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What should the nurse tell the client to provide greater reassurance? 1. Canes prevent falls, not cause them. 2. The physical therapist will determine if the cane is inadequate. 3. The cane would help break a fall, even if the client does slip. 4. The cane has a flared tip with concentric rings to provide stability.

4 (Rationale: A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. The other items about canes are incorrect.)

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours, and put it flat for 1 hour. 3. Keep the leg level for 3 hours, and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.

4 (Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. Therefore, the other options are incorrect.)

A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? 1. In 24 hours 2. In 48 hours 3. In approximately 8 hours 4. Within 20 to 30 minutes of application

4 (Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.)

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which *primary* function? 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4 (Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.) (Test-Taking Strategy(ies): Note the strategic word, primary, and focus on the subject, the function of Buck's extension traction. Recalling the purpose of traction will assist in eliminating options 1 and 3. From the remaining options, eliminate the option with the words rigid immobilization.)

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? 1. Flat with the knee gatch raised 2. In semi-Fowler's position with the foot of the bed flat 3. In high-Fowler's position with the foot of the bed flat 4. In semi-Fowler's position with the knee gatch slightly raised

4 (Rationale: Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the client flat with the knee gatch raised stretches the lower back.)

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client *needs further teaching* if the nurse observes the client doing which activity? 1. Pulling up on the trapeze 2. Flexing and extending the feet 3. Doing quadriceps-setting and gluteal-setting exercises 4. Performing active range of motion (ROM) to the right ankle and knee

4 (Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful.)

The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should *immediately* perform which action? 1. Apply ice to the site. 2. Call the primary health care provider. 3. Apply a dry sterile dressing and elevates it on one pillow. 4. Rewrap the residual limb with an elastic compression bandage.

4 (Rationale: If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the residual limb with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation. Test-Taking Strategy(ies): Note the strategic word, immediately, and focus on the subject, above-the-knee amputation. Eliminate apply a dry sterile dressing and elevate it on one pillow first. Elevation on one pillow is not going to greatly impede the development of edema once compression is released. For the same reason, applying ice to the site is eliminated. Ice would be of limited value in controlling edema from this cause. From the remaining actions, the better option is to reapply the compression bandage. Notifying the primary health care provider is not necessary.)

The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's *initial* action? 1. Reassess the vital signs. 2. Perform a neurological assessment. 3. Place the client in a supine position. 4. Place the client in a Fowler's position

4 (Rationale: If the nurse suspects fat embolism, the initial action by the nurse is to place the client in a sitting (Fowler's) position to relieve dyspnea. Clients with fractures are at risk for fat embolism. Supplemental oxygen is indicated to reduce the signs of hypoxia. The primary health care provider needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions.)

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 1. Selecting shoes that have firm nonskid soles 2. Applying nonskid strips on areas that get wet 3. Installing telephones in several rooms of the house 4. Maintaining body weight at or above minimum recommended levels

4 (Rationale: Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. The other prevention measures are secondary and not primary prevention measures.)

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? 1. Ensure the client receives the daily tablet of enoxaparin. 2. Assist the client in keeping the legs as close together as possible. 3. Remind the client to use a handrail when lowering the hips into a 120-degree flexion. 4. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.

4 (Rationale: Partial weight bearing usually is permitted 72 hours postoperatively per surgeon's preference but the nurse needs to check the surgeon's prescription. The client should keep the knees abducted with a wedge pillow. The client should not flex the hips any more than a 90-degree angle. Enoxaparin is given by injection, not by a tablet.)

The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which *priority* data should be included? 1. The client's fear related to the use of the crutches 2. The client's feelings about the restricted mobility 3. The client's understanding of the need for increased mobility 4. The client's vital signs, muscle strength, and previous activity level

4 (Rationale: Priority data related to vital signs, muscle strength, and previous activity level would be included. Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. The other data are also important, but physiological needs take precedence over psychosocial needs.)

A client is fearful about having an arm cast removed. Which action by the nurse would be the *most* helpful? 1. Telling the client that the saw makes a frightening noise 2. Reassuring the client that no one has had an arm lacerated yet 3. Stating that the hot cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works

4 (Rationale: The action by the nurse that would be the most helpful is to show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side.)

The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client *needs further teaching* if the client verbalizes which action should be done? 1. Increase fiber and fluids in the diet. 2. Bend at the knees to pick up objects. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4 (Rationale: The client needs further teaching if the client says sitting straight up and swinging the legs over the side is the way to get out of bed. Clients are taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed, using one or both arms. The back is kept straight, and the legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects.)

The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client *needs further teaching* if the client makes which statement? 1. "I should avoid walking on wet, slippery floors." 2. "I'm not supposed to scratch the skin underneath the cast." 3. "It's all right to wipe dirt off the top of the cast with a damp cloth." 4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

4 (Rationale: The client needs further teaching if the client states that if the cast gets wet, drying it with a hair dryer turned to the warmest setting is an option. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. Client instructions should include avoidance of walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation.)

The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? 1. "I'm doing this, so I can go home soon." 2. "It hurts, but things always have to hurt at my age." 3. "If I don't do this, that therapist gets really angry at me." 4. "I'm doing these exercises so I can begin to fasten my buttons and dress myself again."

4 (Rationale: The client understands the purpose of the therapy and provides an incentive to comply with the exercises when the client states, "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." The statement, I'm doing this, so I can go home soon" may or may not be true and could relate to a number of factors other than use of the right hand. Saying it hurts but things always hurt at my age is an inaccurate statement. Saying the therapist will get mad if I don't do this is incorrect because it indicates imposition of staff values on the client and is suggestive of possible abuse.)

The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? 1. Obtain a walker to minimize weight bearing by the client on the affected leg. 2. Apply an Ace wrap around the dressing, and put ice on the knee while sitting. 3. Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. 4. Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.

4 (Rationale: The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint for stability. The surgeon prescribes the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema.)

The nurse is preparing a plan of care for a client in skeletal leg traction with an over bed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2. Place a draw sheet under the client for pulling the client up in bed. 3. Encourage the client to pull up by pushing with the unaffected leg on the bed mattress. 4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

4 (Rationale: The nurse can best assist the client in skeletal traction with positioning in bed by providing a trapeze on the bed for the client's use. Encouraging the client to pull up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of positioning by the client.)

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the *initial* nursing action? 1. Elevate the casted leg. 2. Contact the primary health care provider. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg

4 (Rationale: The nurse's initial action is to check the neurovascular status of the toes on the casted leg. An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. The nurse needs to obtain additional data in order to determine whether the primary health care provider needs to be notified immediately or whether other interventions are appropriate. The other actions are inappropriate and would delay treatment if needed.)

The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 1. Morning stiffness 2. Positive rheumatoid factor 3. An elevated sedimentation rate 4. Dull aching pain in the affected joints

4 (Rationale: The sign/symptom associated with osteoarthritis is dull, aching pain that occurs in the affected joints. Unlike rheumatoid arthritis, systemic manifestations are absent and joint involvement is not symmetrical. The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify after activity, and they may be aggravated by cold, damp weather. No specific laboratory findings are useful in diagnosing osteoarthritis. Morning stiffness, an elevated sedimentation rate, and a positive rheumatoid factor occur in rheumatoid arthritis.)

The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a *need for further teaching*? 1. "I need to take high doses of vitamin D." 2. "Calcification does not occur to harden my bones." 3. "Vitamin D helps calcium to be absorbed in my small intestines." 4. "This condition is primarily due to my lack of calcium and testosterone."

4 (Rationale: There is a need for further teaching when the client says that lack of calcium and testosterone cause osteomalacia. Osteomalacia is caused by a lack of vitamin D. It is the softening of bone tissue characterized by inadequate mineralization of osteoid. Osteoporosis is caused by a lack of calcium and estrogen in women and testosterone in men.)

The nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a *need for further teaching?* 1. "I plan to restrict or limit my driving." 2. "I will avoid bending and twisting at the waist." 3. "I'll go for a walk every day, but I won't take the dog." 4. "I'll be careful not to lift anything heavier than 20 pounds."

4 (Rationale: There is a need for further teaching when the client states that "I'll be careful not to lift anything heavier than 20 pounds." The client should not lift anything heavier than *5 pounds*. After conventional open back surgery, the client may have activity restrictions for the first 4 to 6 weeks, such as restricting or limiting driving, limiting daily stair climbing, avoiding bending and twisting at the waist, taking a daily walk, and restricting pushing-and-pulling activities like dog walking.)

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1. Try to manually reduce the fracture. 2. Assist the person with getting up and walking to the sidewalk. 3. Leave the person for a few moments to call an ambulance. 4. Stay with the person and encourage the person to remain still.

4 (Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.)

The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement? 1. "I can resume regular exercise tomorrow." 2. "I will stay off of the leg entirely for the rest of the day." 3. "I need to refrain from eating food for the remainder of the day." 4. "I'll report fever or site inflammation to the primary health care provider."

4 Rationale: The client understands the discharge instructions after a knee arthroscopy if the client plans to report any fever or site inflammation to the primary health care provider. Any signs/symptoms of infection must be reported to the primary health care provider. After arthroscopy the client can usually walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet.)