NCLEX MUSCULOSKELETAL
The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important? 1 Fractures 2 Weight loss 3 Hypocalcemia 4 Muscle atrophy
1 (Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility. The woman is most likely to suffer fractures as a result of this disorder. The remaining options are not directly related to this disorder.)
The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? 1 Presence of fasciculations 2 Muscle strength of normal power 3 Symmetrical movements bilaterally 4 Hypertrophy of right upper arm of 1 cm
1 (Rationale: Fasciculations are fine-muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.)
A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. 1 Ice bags 2 Elevation 3 Heating pad 4 Compression bandage 5 Range-of-motion exercises
1, 2, 4 (Rationale: Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated initially by remembering the acronym RICE, which stands for rest, ice, compression, and elevation. Heat and range-of-motion exercises are contraindicated because they would increase swelling.)
The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. 1 "I should not use someone else's crutches." 2 I need to remove any scatter rugs at home." 3 "I can use crutch tips even when they are wet." 4 "I need to have spare crutches and tips available." 5 "When I'm using the crutches, my arms need to be completely straight."
1, 2, 4 (Rationale: The client should use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.)
The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment? 1 The hip 2 The knee 3 The ankle 4 The great toe
2 (Rationale: A meniscus is an interarticular fibrocartilage that partially or completely separates the components of a joint. The knee is a common area for meniscal tears because it is frequently injured as a result of falls and sports injuries; therefore, options 1, 3, and 4 are incorrect)
The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? 1 The residual limb is washed gently and dried every other day. 2 The socket of the prosthesis must be dried carefully before it is used. 3 A residual limb sock must be worn at all times and changed twice a week. 4 The socket of the prosthesis is washed with a harsh bactericidal agent daily.
2 (Rationale: A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used.)
The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1 Cold, bluish-colored fingers 2 Numbness and tingling in the fingers 3 Pain that increases when the arm is dependent 4 Pain that is out of proportion to the severity of the fracture
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. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.)
The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? 1 Elevate the casted leg. 2 Contact the health care provider. 3 Administer another dose of pain medication. 4 Check the neurovascular status of the toes on the casted leg.
4 (Rationale: An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine if the health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment.)
The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1 "Changes in the shape of the knee are expected." 2 "Fever, redness, and increased pain are expected." 3 "All caregivers should be told about the metal implant." 4 "Bleeding gums or black stools may occur, but this is normal."
3 (Rationale: A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures.)
A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1 Fever and bradycardia 2 Fever and hypertension 3 Tachycardia and hypotension 4 Bradycardia and hypertension
3 (Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.)
A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? 1 Fever, bradycardia 2 Fever, hypertension 3 Tachycardia, hypotension 4 Bradycardia, hypertension
3 (Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and, in the case of a fractured femur, into the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.)
The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1 "A bone fragment has injured the nerve supply in the area." 2 "An injured artery caused impaired arterial perfusion through the compartment." 3 "Bleeding and swelling caused increased pressure in an area that couldn't expand." 4 "The fascia expanded with injury, causing pressure on underlying nerves and muscles."
3 (Rationale: Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.)
The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 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: Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Pressure on a spinal nerve root causes the symptoms of sciatica.)
The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs 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: Fat embolism commonly causes signs and 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 remaining options are incorrect.)
The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1 Contact the health care provider. 2 Massage the skin at the edges of the cast. 3 Petal the cast edges with appropriate material. 4 Place a small facecloth in the cast around the edges of the cast.
3 (Rationale: If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. It is not necessary to contact the health care provider unless skin breakdown is noted. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate.)
The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1 Apply ice to the site. 2 Call the health care provider (HCP). 3 Rewrap the residual limb with an elastic compression bandage. 4 Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.
3 (Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the HCP were called, the prescription likely would be to reapply the compression dressing anyway.)
The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? 1 Ensure that the weight used as a pulling force is at least 20 lb (9 kg). 2 Ensure that the weights rest on the floor and are not freely hanging. 3 Inspect the skin at least every 8 hours for signs of irritation or inflammation. 4 Remove the weights for at least 5 minutes every hour to give the client a rest.
3 (Rationale: It is important for the skin to be assessed at least every 8 hours. Weights should be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and should always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.)
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 elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1 Infection under the cast 2 The anxiety of the client 3 Impaired tissue perfusion 4 The recent occurrence of the fracture
3 (Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.)
The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? 1 Elevating the limb 2 Monitoring vital signs every 4 hours 3 Administering opioid analgesics intramuscularly 4 Monitoring the biopsy site for swelling, bleeding, or hematoma
3 (Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours or as prescribed to reduce edema. The vital signs are monitored every 4 hours for 24 hours for signs of complications such as infection and bleeding. The client usually requires mild analgesics. More severe pain usually indicates that complications are arising.)
A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? 1 prained left ankle 2 Decreased calcium intake 3 Open trauma to the left leg 4 Starting to smoke cigarettes
3 (Rationale: Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.)
The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? 1 Tinnitus 2 Fatigue 3 Bone pain 4 Difficulty with ambulating
3 (Rationale: Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in the skull. Fatigue or difficulty with ambulation may occur but would not be the most common symptom.)
A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? 1 "When I have pain, I will take ibuprofen." 2 "I should perform low-impact exercises regularly." 3 "Because I have no symptoms, my disease is not progressing." 4 "I must notify my health care provider if I experience any hearing loss."
3 (Rationale: Paget's disease is characterized by skeletal deformities caused by abnormal bone resorption followed by abnormal regeneration. It is a chronic disease, and most persons who are affected by it are asymptomatic. Even though there may be no symptoms, excessive bone loss may have occurred. Over-the-counter nonsteroidal antiinflammatory drugs may be used for pain, and low-impact exercises may reduce pain and increase mobility. Bones in the ear may be affected, and pressure from an enlarged temporal bone may cause hearing loss. If hearing loss occurs, the health care provider is notified.)
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 is the priority nursing action? 1 Provide pin care. 2 Medicate the client. 3 Call the health care provider. 4 Remove 2 pounds (0.9 kg) of weight from the traction system.
3 (Rationale: Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so.)
The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? 1 The pain level of the client 2 Blood pressure and respiratory rate 3 Capillary refill, sensation, color, and pulse of the left foot 4 The range of motion of the left knee when a continuous passive motion machine is used
3 (Rationale: The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a neurovascular assessment. Monitoring the pain level may be a component of the assessment but is not specifically related to neurovascular status. Blood pressure and respiratory rate may also be components of the nursing assessment but are not specific to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular status.)
The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1 Capillary refill is less than 3 seconds 2 Pulses present and with swollen, pink fingers 3 Client report of severe, deep, unrelenting pain 4 Client report of pain as nurse assesses finger movement 5 Client report of numbness and tingling sensation in the fingers
3, 4, 5 (Rationale: The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.)
The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply. 1 Elevated white blood cell count 2 A decreased sedimentation rate 3 Joint pain that diminishes after rest 4 Elevated antinuclear antibody levels 5 Joint pain that intensifies with activity
3, 5 (Rationale: The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.)
The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? 1 Pulling up using the trapeze 2 Flexing and extending the feet 3 Doing quadriceps-setting and gluteal-setting exercises 4 Performing active range of motion to the right ankle and knee
4 (Rationale: Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion.)
A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using which best method? 1 A bath blanket and the assistance of four people 2 A bath blanket and the assistance of three people 3 A transfer (slider) board and the assistance of two people 4 A transfer (slider) board and the assistance of three people
4 (Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer (slider) board and the assistance of three people with one at the head to protect or support the client's head and neck. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently.)
The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? 1 Open 2 Displaced 3 Complete 4 Incomplete
4 (Rationale: An incomplete fracture is one that extends through only part of the thickness of the bone. These fractures usually are nondisplaced, meaning that the bone remains in the normal position. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tissue. A complete fracture is one that extends through the full thickness of bone and often is displaced, meaning that the bone moves out of normal position.)
A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery 1 Hemorrhage 2 Edema of the residual limb 3 Slight redness of the incision 4 Separation of the wound edges
4 (Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact.)
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? 1 Flat with the knees raised 2 In high Fowler's position, with the foot of the bed flat 3 In semi Fowler's position, with the foot of the bed flat 4 In semi Fowler's position, with the knees slightly flexed
4 (Rationale: Clients with low back pain often are more comfortable when placed in Williams' position. 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. The remaining positions will not minimize the pain and may make the pain worse.)
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: Individuals may be fearful of having a cast removed because of misconceptions about the cast-cutting blade. The nurse should show the cast cutter to the client before it is used and explain that he or she may feel heat, vibration, and pressure. 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 remaining options will increase the client's fear about the procedure.)
A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? 1 "The bathroom has hand railings in the shower." 2 "There are three steps to get up to the front door." 3 "My family has rented a commode for me to use." 4 "My bedroom and bathroom are on the second floor of my home."
4 (Rationale: Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails should be installed and the area kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.)
The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? 1 Signs of infection are absent. 2 The muscles are beginning to relax. 3 Abscess formation has not occurred. 4 There is reabsorption of blood noted at the injured site.
4 (Rationale: The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to prevent infection or abscess formation.)
The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? 1 Take a set of vital signs. 2 Call the radiology department. 3 Reassure the client that everything will be fine. 4 Immobilize the right leg before moving the client.
4 (Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a health care provider is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiographs. Telling the client that everything will be fine is nontherapeutic. Although vital signs will be taken, the priority is to immobilize the leg.)
The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1 Try to reduce the fracture manually. 2 Assist the victim to get up and walk to the sidewalk. 3 Leave the victim for a few moments to call an ambulance. 4 Stay with the victim and encourage him or her to remain still.
4 (Rationale: With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.)
The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? 1 Yogurt 2 Turkey 3 Shellfish 4 Spaghetti
1 (Rationale: The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.)
Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1 Keep the cast clean and dry. 2 Allow the cast 24 to 72 hours to dry. 3 Keep the cast and extremity elevated. 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 should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand 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 on a plaster cast 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 health care provider is notified immediately if circulatory impairment occurs.)
The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. 1 Thin body build 2 Smoking history 3 Postmenopausal age 4 Chronic corticosteroid use 5 High intake of dairy products 6 Family history of osteoporosis
1, 2, 3, 4, 6 (Rationale: A high intake of dairy products is not associated with osteoporosis because dairy products are high in calcium. Other than low calcium intake, other risk factors for osteoporosis include a thin body frame, sedentary lifestyle, cigarette smoking, excessive alcohol intake, chronic illness, long-term use of corticosteroids, postmenopausal age, and a family history of osteoporosis.)
The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. 1 Physical therapy 2 Knee immobilizer 3 Aspiration of joint fluid 4 Ambulation with a walker 5 Antiinflammatory medications
1, 2, 3, 5 (Rationale: The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, antiinflammatory medications, rest, ice, and possibly reconstructive surgery.)
The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items should the nurse recommend as being high in calcium? Select all that apply. 1 Tofu 2 Salmon 3 Peaches 4 Spinach 5 Sardines
1, 2, 4, 5 (Rationale: Foods high in calcium include milk and milk products, dark green leafy vegetables, tofu and other soy products, sardines, salmon with bones, and hard water. Options 1, 2, 4, and 5 are all foods that are high in calcium. Peaches are high in vitamins A and C.)
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. 1 Pyrexia 2 Elevated potassium level 3 Elevated white blood cell count 4 Elevated erythrocyte sedimentation rate 5 Bone scan impression indicative of infection
1, 3, 4, 5 (Rationale: Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.)
The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1 Twisting of the spine 2 Curvature of the spine 3 Hyperflexion of the spine 4 Sciatic nerve inflammation 5 Degeneration of the facet joints 6 Herniation of an intervertebral disk
1, 3, 6 (Rationale: Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.)
The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. 1 Fatigue 2 Weight gain 3 Restlessness 4 Morning stiffness 5 Pain with movement only
1, 4 (Rationale: Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.)
The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? 1 "The cast will give off heat as it dries." 2 "I can bear weight on the cast in one-half hour." 3 "The cast edges may be trimmed with a cast knife." 4 "A stockinette will be placed over the leg area to be casted."
2 (Rationale: A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours, depending on the nature and thickness of the cast. A plaster cast gives off heat as it dries. 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 client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? 1 pH 2 Pao2 3 HCO3 4 Paco2
2 (Rationale: A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2 often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results.)
The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? 1 Document the findings. 2 Notify the health care provider. 3 Apply antibiotic ointment to the pin sites. 4 Clean the pin sites more frequently than prescribed.
2 (Rationale: A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be reported to the health care provider. Options 1, 3, and 4 are inappropriate nursing actions for this client before cleaning a newly assessed potentially infected pin site; the site would be cultured before either cleaning it or putting medication on it.)
The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1 A trochanter roll to prevent abduction during turning 2 A pillow to keep the right leg abducted during turning 3 A pillow to keep the right leg adducted during turning 4 A trochanter roll to prevent external rotation during turning
2 (Rationale: After femoral head replacement for a fractured hip with an intracapsular 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 nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned.)
The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the 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 self-adhering 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: After spinal surgery, a brace or corset may be required temporarily to support the spine. Clients who have lumbar or thoracic spinal fusions wear a fiberglass brace, which resembles a shell. Initially, back braces or corsets may be worn constantly, whether the client is in or out of bed. If not required constantly, the brace is applied in the morning before getting out of bed. As the client's muscles strengthen, the use of braces or corsets is usually decreased. A back brace or thoracolumbosacral orthosis is individually fitted to the client. A layer of clothing is worn between the orthosis and the skin. The closures should be secure but not overly loose or tight. The brace should not irritate the skin with proper fitting. Always follow the health care provider's activity prescriptions.)
The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? 1 Arterial insufficiency 2 Impaired venous return 3 Impaired arterial circulation 4 The presence of an infection
2 (Rationale: Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast.)
The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? 1 The client moves both crutches forward and then swings both feet forward to the crutches. 2 The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 3 The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. 4 The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.
2 (Rationale: In a three-point gait the client is instructed to simultaneously move both crutches and the affected leg forward and then to move the unaffected leg forward. Option 1 identifies a swing-through gait. Options 3 and 4 identify a four-point gait.)
A client has been experiencing muscle weakness over a period of several months. The health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? 1 "If I have polymyositis, there will be a decrease in elastic tissue." 2 "I will know I have polymyositis if the muscle fibers are inflamed." 3 "The health care provider said there would be more fibers and tissue with polymyositis." 4 "The health care provider said if the muscle fibers were thickened, I would have polymyositis."
2 (Rationale: In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is the opposite of what is noted in this disorder.)
The nurse is caring for a client diagnosed with the rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected? 1 Nerve 2 Tendon 3 Ligament 4 Synovial fluid
2 (Rationale: Lesions of the rotator cuff often involve the supraspinatus tendon of the shoulder. Although the entire joint is painful, the etiology does not involve nerves, ligaments, or synovial fluid. Usually the problem involves one or more of the tendons and muscles in the musculotendinous cuff. It most often is the result of minor repeated traumas or degenerative changes in the older client or the result of severe trauma in the younger client.)
The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? 1 Muscle metabolism and growth 2 Bone resorption and regeneration 3 Nervous system impulse transmission 4 Joint integrity and synovial fluid production
2 (Rationale: Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning.)
The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? 1 Tuberculin test 2 Tetanus vaccine 3 Chest radiograph 4 Physical examination
2 (Rationale: With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.)
A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply .1 Use the overhead trapeze. 2 Keep the head of the bed flat. 3 Place pillows under the length of the legs. 4 Use logrolling technique for repositioning. 5 Assist the client with eating meals and drinking fluids.
2, 3, 4, 5 (Test-Taking Strategy: Focus on the subject, safe interventions after spinal fusion. After spinal surgery, the nurse uses positioning techniques that will keep the spine in good alignment. Thus, the options of keeping the head of the bed flat and using logrolling technique are indicated measures. Regarding the remaining options, recall that using pillows under the length of the legs promotes slight flexion of the spine while avoiding pressure on the popliteal space (which predisposes to thrombophlebitis) and that if the client is flat then assistance is needed with drinking and eating. Using an overbed trapeze could allow the client to twist the spine, which is directly contraindicated.)
The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1 The need for sensory stimulation 2 The amount of home care support available 3 The ability to perform activities of daily living 4 The type of transportation available for follow-up care
1 (Rationale: A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.)
The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? 1 Document the findings. 2 Notify the health care provider (HCP). 3 Remove 2 pounds (0.9 kg) of weight from the traction. 4 Lift the weights and place them on the bed so that the HCP can assess the client.
1 (Rationale: A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the HCP. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.)
The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? 1 Limit caffeine intake. 2 Limit intake of vitamin D. 3 Limit participation in activities such as walking and swimming. 4 Limit protein in the diet because it contributes to the incidence of bone demineralization.
1 (Rationale: Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium.)
The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction? 1 Bends over to tie shoes 2 Sits in a recliner with feet elevated 3 Squats to pick up an item from the floor 4 Sleeps in a side-lying position with knees and hips bent
1 (Rationale: To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking up things or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.)
A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply 1 .Infection 2 Recent injury 3 Inflammation 4 Degenerative disease 5 Developmental retardation
1, 2, 3 (Rationale: Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur. These symptoms are not specifically associated with developmental retardation.)
The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. 1 Use night lights. 2 Remove scatter rugs. 3 Use staircase railings. 4 Remove wall-to-wall carpeting. 5 Place hand rails in the bathroom.
1, 2, 3, 5 (Rationale: Home modifications to reduce the risk for falls include using railings on all staircases, providing ample lighting, removing scatter rugs, and placing hand rails in the bathroom. Removing wall-to-wall carpeting is not necessary as long as it is in good condition.)
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1 Ice 2 Heat 3 Analgesics 4 Muscle relaxers 5 Intermittent traction
2, 3, 4, 5 (Rationale: Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.)
Which tests can be used to diagnose gout? Select all that apply. 1 Renal ultrasound 2 Serum uric acid level 3 Bone marrow biopsy 4 Urinalysis with culture 5 Synovial fluid aspiration 6 24-hour urine uric acid level
2, 5, 6 (Rationale: Diagnostic tests for gout include serum uric acid level and 24-hour urine uric acid level, as well as synovial fluid aspiration and x-ray of the affected areas. Renal ultrasound, bone marrow biopsy, and urinalysis with culture are not specifically associated with gout; they test for a variety of other conditions.)
A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? 1 Lack of control 2 Lack of physical mobility 3 Inability to entertain self 4 Inability to maintain health
3 (Rationale: A manifestation of the inability to entertain self is expression of boredom by the client. The question does not identify difficulties with coordination, range of motion, or muscle strength, which would indicate lack of physical mobility. The question also does not relate to client feelings of inability to take responsibility for meeting basic health practices (inability to maintain health) or to lack of control.)
The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? 1 Fractured knee 2 Dislocated knee 3 Fracture of the femoral neck 4 Fracture of the midshaft of the femur
3 (Rationale: Typical signs after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. The signs noted in the question are not associated with a fractured or dislocated knee or a fractured femur.)
The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? 1 Simple fracture 2 Greenstick fracture 3 Compound fracture 4 Comminuted fracture
4 (Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.)
The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? 1 "I should sit in my recliner when I get home." 2 "I need to keep my legs apart while sitting or lying." 3 "I should try to obtain an elevated toilet seat for use at home." 4 "I should contact the health care provider if the incision becomes red or irritated or if I note any drainage."
1 (Rationale: After total hip replacement, the client should be instructed to sit on a high, firm chair. The client should be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The health care provider should be notified if the client notes the development of any redness, irritation, or drainage at the incision site.)
The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1 Restricting fluids 2 Maintaining bed rest 3 Eating a low-purine diet 4 Taking nonsteroidal antiinflammatory drugs
1 (Rationale: Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bed rest during an acute attack until the pain subsides. A diet low in purine normally is prescribed. Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid.)
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1 Clear mentation 2Minimal dyspnea 3 Oxygen saturation of 85% 4 Arterial oxygen level of 78 mm Hg (10.3 kPa)
1 (Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen saturation should be higher than 95%.)
A client is seen in the health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve? 1 Median 2 Peroneal 3 Trigeminal 4 Spinal accessory
1 (Rationale: Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of injury, overuse, or disease. The peroneal nerve is in the leg. Trigeminal neuropathy results in facial pain, also known as tic douloureux. The spinal accessory nerve is a motor nerve impacting shoulder function.)
A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should assess which area as high risk for pressure and breakdown? 1 Left heel 2 Scapulae 3 Right heel 4 Back of the head
1 (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. Scapulae and the back of the head are not common areas for pressure ulcers for this client. The right heel is elevated because of traction.)
The nurse is evaluating a 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 performs 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 (15 cm) 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 to provide a wide base of support. The cane is held 4 to 6 inches (10 to 15 cm) lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through.)
The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? 1 Fever and chills 2 Dyspnea and chest pain 3 External rotation of the right leg 4 Pallor, paresthesia, and pulselessness of the right lower leg
2 (Rationale: The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment)
The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1 Hypotension 2 Weak pedal pulses 3 Redness at the pin sites 4 Drainage at the pin sites
2 (Rationale: Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, redness and/or drainage at the pin sites are incorrect. Hypotension is not directly associated with the use of this type of traction.)
The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1 Make sure that the knots are at the pulleys. 2 Inspect the skin under the boot at least every 8 hours. 3 Make sure the head of the bed is kept at a 45- to 90-degree angle. 4 Monitor the weights to be sure that they are resting on a firm surface.
2 (Rationale: When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device for skin irritation and breakdown. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.)
The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. 1 Lying prone 2 Sitting using a lumbar roll or pillow 3 Standing with one foot on a step or stool 4 Lying on the side, with knees and hips straight 5 Lift objects that need to be carried above elbow level. 6 Lean forward to reach objects, keeping the legs and knees straight.
2, 3 (Rationale: The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level.)
A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? 1 Remove the client's shoes. 2 Place the client in a semi Fowler's position. 3 Check the neurovascular status of the area distal to the extremity. 4 Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.
3 (Rationale: To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill. Tourniquets are not used to control hemorrhage in extremities because of the risk of tissue ischemia. Direct pressure is applied at the site and over the proximal artery nearest the fracture if bleeding occurs. Clients need to be kept in a supine position to help prevent hypotension and shock. Shoes are not removed because this action may cause increased trauma.)
The nurse determines that a client's skeletal traction needs correction if which observation is made? 1 Weights are not touching the floor. 2 Weights are hanging free of the bed. 3 Traction ropes rest against the footboard. 4 Traction ropes are aligned in each pulley.
3 (Rationale: Traction ropes must hang free of the bed. The remaining options are observations that indicate correct use of the traction setup.)
A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 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 (The part of the bed under an area in traction usually is 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. The remaining options are incorrect.)
A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? 1 It is strained. 2 It is contused. 3 It has completely dislocated. 4 It has incompletely dislocated.
4 (Rationale: A dislocation is the disruption of a joint to the extent that the articulating surfaces are no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces. Because the disruption is less severe, healing time is less prolonged. A strain occurs when a muscle or ligament is used beyond the limit of its functional ability. It is characterized by overstretching of the muscle or ligament and also could involve tearing if the strain is more severe (i.e., second- or third-degree strain versus first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into the involved tissue.)
A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? 1 "Flushing indicates a complication." 2 "I should stay on liquids for a couple of days." 3 "I need to ambulate every couple of hours faithfully for a few days." 4 "I need to drink plenty of water for 1 to 2 days after the procedure."
4 (Rationale: No special restrictions are necessary after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The very small amount of radioactivity from the isotope presents no hazard to the client or staff. The remaining options are unrelated to postprocedure care.)
The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? 1 Shortening and abduction 2 Abduction and internal rotation 3 Shortening and internal rotation 4 Shortening and external rotation
4 (Rationale: Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.)