Med Surg - Musculoskeletal

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? a. Sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing

A. Sudden onset of dyspnea---Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs. Incorrect Answers: B. Tracheal deviation is an indication of pneumothorax. C. Tachycardia is a clinical manifestation of pulmonary embolism. D. Difficulty swallowing is an indication of many conditions, including oral cancer.

A nurse is teaching a client who has a new prescription for warfarin. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll use a safety razor to shave each day." b. "I'll be sure to eat lots of spinach." c. "I'll avoid contact sports like football." d. "I'll take ibuprofen if I get a headache."

C. "I'll avoid contact sports like football." ---The most common adverse effect of taking anticoagulants is bleeding. Therefore, the client should avoid any activities that have a high risk of causing injury, such as contact sports.

A nurse is caring for a client who takes warfarin 2.5 mg PO daily and has an INR of 6.2. The nurse should anticipate a prescription from the provider for which of the following medications? a. Protamine sulfate b. Fondaparinux c. Vitamin K d. Bivalirudin

C. Vitamin K---The nurse should anticipate the provider to prescribe vitamin K for a client who has an INR of 6.2. Vitamin K antagonizes warfarin's actions, which can reverse warfarin-induced inhibition of clotting factor synthesis.

A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take? A. Elevate the affected leg B. Place the client on bed rest C. Massage the affected leg D. Administer aspirin for discomfort

A. Elevate the affected leg--- The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.

A nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (Select all that apply.) a. Hardening along the blood vessel b. Absence of a peripheral pulse c. Tenderness in the calf d. Cool skin on the leg e. Increased leg circumference

A. Hardening along the blood vessel C. Tenderness in the calf E. Increased leg circumference--- Deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? a. Offering the client a diet high in fluid and fiber b. Encouraging active range of motion of the affected leg c. Removing the weights prior to repositioning the client d. Inspecting pin sites every 24 hr for drainage

A. Offering the client a diet high in fluid and fiber---- A client who is immobile is at risk of constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function. Incorrect Answers: B. Active range of motion of the unaffected limbs is encouraged to prevent muscle wasting; however, active range of motion of a limb in traction is not feasible, as the traction apparatus limits mobility. C. Once the weights are in place, the nurse should not remove them. D. The nurse should plan to inspect the client's pin sites at least every 8 to 12 hours due to the risk of infection.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify which of the following findings is a manifestation of a pulmonary embolism? a. Stabbing chest pain b. Calf tenderness c. Elevated temperature d. Bradycardia

A. Stabbing chest pain---- A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.

A nurse is providing discharge teaching to a client who has venous thrombosis and a prescription for warfarin. Which of the following instructions should the nurse include in the teaching? a. Take ibuprofen as needed for headaches or other minor pains b. Carry a medical alert ID card c. Report to the laboratory weekly to have blood drawn for aPTT d. Increase intake of dark green vegetables

B. Carry a medical alert ID card---A client who is taking warfarin is at increased risk for bleeding. In the case of an emergency, any medical personnel must be aware of the client's medication history.

A nurse is caring for a client who has a fractured hip and was placed in Buck's traction 4 hr ago. Which of the following actions should the nurse take? a. Inspect the client's skin underneath the boot every 12 hr b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr c. Remove the weights from the traction while repositioning the client in bed d. Loosen the ropes if the client reports muscle spasms in the affected extremity

B. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr ---The nurse should encourage the client to perform dorsiflexion of the affected extremity every 2 hours to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately. Incorrect Answers: A. The nurse should inspect the client's skin underneath the boot for irritation, increased swelling, and skin breakdown every 8 hours. C. The weights should never be removed without a prescription from the provider. The purpose of the weights is to decrease muscle spasms as a result of the hip fracture. D. The ropes of the traction should never be loosened. This can affect the traction and increase the client's muscle spasms.

A nurse is caring for a client who is in skeletal traction following a femur fracture. On entering, the nurse finds that the client has slid toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take? a. Remove the weight temporarily to reposition the client to the correct alignment in bed b. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely c. Lift the rope off the pulley while the client rocks back and forth to reposition himself d. Lift the weight manually while another staff member moves the client up in bed

B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely---The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity.

A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? a. Remind the client to push the button for the PCA device b. Discuss activities the client may use to distract from the pain c. Ask the client to describe the characteristics of the pain d. Pause the CPM machine briefly to apply a cold pack to the client's knee

C. Ask the client to describe the characteristics of the pain--- The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? a. Ecchymosis of the thigh b. Serous drainage at the pin site c. Chest petechiae d. Muscle spasms in the left leg

C. Chest petechiae--- The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones such as the femur are at increased risk of fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure.

A nurse in the emergency department is preparing to discharge a client following a Grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client? a. Perform passive range-of-motion exercises of the ankle hourly b. Keep the affected extremity in a dependent position c. Wrap a loose dressing around the affected ankle d. Apply cold compresses to the extremity intermittently

D. Apply cold compresses to the extremity intermittently--- Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 minutes at a time.

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. Have the client gently blow clots from the nose every 5 min b. Instruct the client to sit with his head hyperextended c. Apply ice compresses to the back of the client's neck d. Apply lateral pressure to the client's nose for 10 min

D. Apply lateral pressure to the client's nose for 10 min---- The nurse should apply direct, lateral pressure to the nose for 10 minutes to control epistaxis. If after 10 minutes the epistaxis continues, the client might require nasal packing or other interventions.

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery? a. Balanced skeletal traction b. Pelvic belt c. Pelvic sling d. Buck's traction

D. Buck's traction---Buck's traction is used prior to hip arthroplasty to maintain alignment and prevent muscle spasms prior to surgery. Incorrect Answers: A. Balanced skeletal traction is used to stabilize fractures of the femur or pelvis, not the hip. Skeletal traction involves the surgical insertion of pins, tongs, wires, or screws; this is sometimes used to stabilize long bone and vertebral fractures. B. A pelvic belt is used to treat back pain and does not provide traction prior to hip arthroplasty. C. A pelvic sling is used to stabilize pelvic fractures, not hip fractures.

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? a. Move the client from supine to a low Fowler's position every 2-3 hr to help prevent orthostatic hypotension b. Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema c. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications d. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis---- Antiembolic exercises (e.g. flexion of the knees and rolls and pumps of the feet and ankles) every 1-2 hours help prevent thrombophlebitis, which is a complication of immobility.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify which of the following rights of delegation should have prevented this situation from occurring? a. Right task b. Right circumstance c. Right person d. Right communication

D. Right communication--- The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply.) a. "You'll have considerably less pain with the traction in place." b. "You'll have the traction in place for a week or so." c. "The traction will help decrease muscle spasms." d. "The weights act as a pulling force to keep your leg and hip still." e. "We have to make sure the weights are just barely touching the floor."

A. "You'll have considerably less pain with the traction in place." C. "The traction will help decrease muscle spasms." D. "The weights act as a pulling force to keep your leg and hip still." Pain is usually more severe without the traction. Buck's extension traction uses weights to help decrease muscle spasms. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg preoperatively.

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? a. Encourage the client to take deep breaths b. Observe the rate, depth, and character of the client's respirations c. Prepare to administer oxygen d. Give the client a back rub to promote relaxation

B. Observe the rate, depth, and character of the client's respirations--- The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status.

A nurse is planning care for a client who is postoperative and scheduled to ambulate. At which of the following times should the nurse plan to administer PO morphine to the client for peak analgesic effect during the ambulation? a. 3 to 4 hr before ambulation b. 10 to 15 min prior to ambulation c. 60 to 90 min prior to ambulation d. Immediately before ambulation

C. 60 to 90 min prior to ambulation--The peak effect of PO morphine takes 60 to 90 minutes to occur. Medicating the client 60 to 90 minutes prior to ambulation will provide the greatest analgesic effect.

A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? a. With the leg on the affected side adducted b. With the hip externally rotated on the affected side c. With the leg on the affected side abducted d. With the hip flexed to 90° on the affected side

C. With the leg on the affected side abducted---The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.