Musculoskeletal

The nurse is assigned to care for a client who had a total hip replacement an hour ago. Which of the following should the nurse assess first? 1. Amount of drainage in suction drainage device 2. Client's level of pain and last dose of pain medication 3. Proper placement of the abduction pillow 4. Urine in the catheter bag for presence of cloudiness or pus

1 Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis, and infection. Option 1: Total joint replacements carry a risk of serious blood loss. The nurse should check the drainage device and dressing frequently to monitor blood loss, especially during the first several hours post-op. Option 2: Pain is important and should be assessed, but hemorrhage is a priority. Option 3: Proper placement of abduction pillow ensures the hips do not flex more than 90 degrees, which could dislocate the prosthesis. Option 4: Assessing urine is important in any post-op client, but is not specific to a hip replacement surgery.

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning." 2. "I can't take any of the pain meds because it makes me feel sick." 3. "I have to scratch under the cast with a nail file because of the itching." 4. "I noticed a warm spot on my cast, and a bad smell coming from it.

1 Always place neurovascular concerns as the priority! A sudden inability to extend fingers can be caused by swelling, which may be compartment syndrome. This can lead to ischemia and tissue death or permanent wrist contractures. Never place anything in the cast (objects, lotions, powders, etc.)

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed 3. Loosens the Velcro straps when the client reports that the boot is too tight 4. Provides the client with a fracture pan for elimination needs

1 Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Option 1: Raising the head >45 degrees could cause sliding. HOB should be <30 degrees. Option 2: Holding the wait during repositioning prevents excess pulling in the extremity. Option 3: Too tight straps can impair neurovascular integrity. A neurovascular assessment should be completed 30 minutes after any change to the boot (tightening, loosening, re-adjusting, etc.). Option 4: Fracture pans are smaller than a bed pan, and allow for elimination without much moving.

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first? 1. Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf 2. Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago 3. Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers 4. Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice

1 Deep vein thrombosis (DVT) is a thrombus (blood clot) developing in a deep vein, usually in a lower limb. It can occur from anything that prevents adequate blood circulation, such as injury to a vein, surgery, meds, or limited movement. Sometimes clots dissolve on their own, or other times they require surgery. Option 1: Cramping calf pain is a sign of DVT, which can occur after joint surgery. Option 2: Itching is expected with a cast. Directing cool air from a blow dryer into the cast can relieve this. Option 3: The crutches may not be adjusted correctly. Option 4: Pain and swelling are common after a ligament injury.

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene? 1. Elevating a client's residual limb on a pillow 1 day after above-the-knee amputation 2. Placing an abductor pillow between a client's legs after total hip replacement 3. Positioning a client with Buck traction supine with the foot of the bed raised 4. Using pillows to raise a client's extremity following cast placement

1 Option 1: A residual limb is the portion of the limb that's remaining after an amputation. Elevating the limb that soon post-op can cause hip flexion contractures. Edema should be managed using a compression bandage. Option 2: An abductor pillow prevents the client's prosthetic hip from dislocating from the socket. Option 3: Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The HOB should be <30 degrees. Option 4: The affected limb should be raised for 48 hours after cast placement to promote venous return and decrease edema.

The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures. Which client should the nurse assess first? 1. Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness 2. Client who has purulent drainage oozing from a skeletal traction pin insertion site and a temperature of 100.8 F 3. Client with a hip fracture receiving continuous IV saline with bilateral 2+ pitting leg edema and a blood pressure of 176/89 mmHg 4. Client with a rib fracture who is breathing at a rate of 23/min and is reporting 8/10 pain that is worse with inspiration

1 Option 1: Long bone fractures may develop a fat embolus. Signs of FES include dyspnea, tachycardia, chest pain, and petechiae on the chest. Option 2: Purulent discharge and fever are signs of an infection, and can progress to osteomyelitis (bone infection). Option 3: Edema and increased BP can be signs of excess fluid volume. Option 4: Clients with rib fractures will take rapid, shallow breaths. Adequate pain control for this patient is crucial for deep breathing to prevent atelectasis and pneumonia.

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider immediately? 1. Distended abdomen and absent bowel sounds 2. Ecchymosis over the pelvic bones 3. Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) 4. Tenderness over the right heel

1 The pelvis contains a lot of large vessels and organs; the nurse should assess for internal hemorrhage (abd distension, vitals), paralytic ileus (bowel sounds), neurovascular deficits (cap refill, sensation, ROM), and GU organ injuries (hematuria, urine output <30 ml/hr). Option 1: Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures. Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal hematoma Option 2: Ecchymosis, bruising, and tenderness are to be expected over an injured bone is to be expected; if the ecchymosis is over the suprapubic area, then it should be reported because it could indicate organ damage or internal hemorrhage. Option 3: A hemoglobin of 11.5 g/dL and Hct of 34% are only slightly below normal (Hgb 14-18 M/12-16 F; Hgb 41-50% M/37-48% F) Option 4: Heel tenderness or pain or expected after a fall, if that area was injured. As long as there are no neurovascular symptoms associated with it (tingling, numbness in the heel or foot), then it's not a priority.

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary? 1. "I will concentrate on leaning forward as I carefully sit down in a chair." 2. "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." 3. "I will use the sock puller that the therapist gave me when I get dressed." 4. "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!"

1 To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the clinic if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast

1, 2, 3 Option 1: Heat/foul odor may indicate an infection Option 2: Getting a cast wet can damage it. Option 3: Elevating the limb reduces edema. Option 4: Numbness/tingling is NOT normal and could be a sign of neurovascular alterations. Option 5: Don't stick anything in the cast.

A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply. 1. "I will avoid foods high in calcium and phosphorus." 2."I will avoid going outside on sunny days." 3."I will decrease activity to prevent bone injury." 4."I will eat foods that are fortified with vitamin D." 5."I will use a cane to help me get around better."

1, 2, 3 Osteomalacia is a reversible bone disorder caused by a deficiency in vitamin D. Without vitamin D, the GI tract cannot absorb calcium and phosphorous, causing bones to become weak, soft, and brittle. Option 1: Clients with osteomalacia need to continue to consume calcium and phosphorous; once vitamin D supplementation begins, these minerals will be better absorbed. Option 2: Sunlight is the best source of vitamin D. Option 3: Activity should be increased, to promote bone growth and repair (calcium absorption). Option 4: Increased vitamin D intake treats osteomalacia. Option 5: People with osteomalacia are at an increased risk of falls.

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply. 1.Assess for skin breakdown of the limb in traction 2.Ensure adequate pain relief 3.Keep the limb in a neutral position 4.Perform frequent neurovascular checks on the limb in traction 5.Reposition the client and use a wedge pillow

1, 2, 3, 4 Positions in Buck's traction are not repositioned, as repositioning side to side can cause injury to the affected leg.

A nurse prepares a client for knee arthroscopy requiring general anesthesia. Which actions should the nurse complete? Select all that apply. 1.Encourage the client to void prior to surgery 2.Ensure that the client has been on NPO status 3.Place signed informed consents in the client's chart 4.Replace the current 20-gauge IV catheter with an 18-gauge 5.Witness that the correct surgery site is marked by the surgeon

1, 2, 3, 5 Option 1: Clients should void prior to surgery, because anesthesia can cause urine retention. Option 2: NPO status will prevent aspiration during surgery. Option 3: Informed consent must always be signed prior to any invasive procedure. Option 4: Although an 18 gauge IV is preferred if there is a need for blood product transfusion, it's not necessary to replace an already present IV. Option 5: The surgery site should be verified with the patient, as well, to ensure it's correct.

The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the following instructions should the nurse include? Select all that apply. 1.Assess the residual limb daily for redness or irritation 2.Keep limb socks and elastic wraps clean and dry 3.Lie on your stomach three times a day for 30 minutes 4.Massage the residual limb with lotion each day 5.Wash the residual limb daily with soap and water

1, 2, 3, 5 Options 1, 2, 5: The residual limb needs to be assessed for signs of infection daily, washed daily to prevent infection, and dried thoroughly to prevent maceration. Option 3: Lying on stomach can prevent hip flexion contractures, which are common complications of knee amputations. Option 4: Irritants (lotion, alcohol, powders) should be avoided on residual limbs.

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply. 1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 3. Internal rotation of the affected extremity 4. Muscle spasm around the affected area 5. Shortening of the affected extremity

1, 2, 4, 5 Option 1: The femur is very vascular and a fracture and result in significant blood loss (>1000 ml). Option 2: Duh. Option 3: The affected limb is usually externally rotated, not internally. Option 4: Muscles around the injured bone will contract to try to protect and stabilize the affected area, causing muscle spasms. Option 5: The fracture can reduce the length of the bone.

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply. 1. Crepitus with joint movement 2. Low-grade fever 3. Morning stiffness lasting 10 to 15 minutes 4. Pain exacerbated by weight-bearing activities 5. Positive serum rheumatoid factor

1, 3, 4, Osteoarthritis (OA) is a degenerative disorder of synovial joints where the articular cartilage and bone beneath the cartilage are destroyed. Bone spurs (osteophytes), calcification, and ulcerations develop in the joint space as the cushioning breaks down. Arthroplasty is an orthopedic surgical procedure where the articular surface of a joint is replaced with a prosthetic. Option 1: Crepitus (grating noise with movement) is caused by the bone and cartilage fragments in the joint floating around. Option 2: A low grade fever is a sign in infection and is not a normal finding. OA is not inflammatory, unlike rheumatoid arthritis, so it would not cause a fever. Option 3: Morning stiffness is normal with OA and usually subsides within 30 minutes Option 4: OA causes decreased joint mobility and ROM, causing atrophy of the muscle. Option 5: Serum rheumatoid factor would be seen in a client with rheumatoid arthritis. There are no biomarkers for osteoarthritis.

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. 1.Keep a clear path to the bathroom 2.Look down at the feet when walking 3.Remove scatter rugs from floors 4.Use a small backpack/shoulder bag to hold personal items 5.Wear rubber-soled shoes, preferably without laces

1, 3, 4, 5 Options 1, 3: To prevent falls, any clutter, unsecured, or hazardous items should be removed from the home. Option 2: You should look forward when walking to maintain an upright position and maintain balance. Option 4: Small bags closer to the trunk will allow the client to remain hands free and keep weight in the center. Option 5: Shoes should be non-skid and close-toed.

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply. 1. Achieve and maintain a healthy weight 2. Avoid foods containing protein 3. Drink plenty of fluids 4. Increase meat intake 5. Limit alcohol consumption

1, 3, 5 Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Option 1: Lifestyle risk factors include obesity, HTN, hyperlipidemia, and insulin resistance. Option 2: Gout is caused by high purine intake, not high protein. High purine foods include organ meat, seafood, and cured meats. A low fat diet will also help prevent gout, as fat impairs urinary excretion of urates. Option 3: Adequate fluid intake facilitates excretion of extra uric acid from the body. Option 4: Meat contains purines, so increasing meat intake with exacerbate gout. Option 5: Alcohol can cause gout (especially beer).

The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply. 1. Assess for increasing drainage from pin sites 2. Check for loose pins and tighten them if loose 3. Maintain bed rest until the device is removed 4. Monitor pulses distal to the external fixation device 5. Perform pin care with a sterile cleaning solution.

1, 4, 5 An external fixator is a device used to stabilize broken bones using metal pins connecting the bones to a frame. Option 1: The pin sites should be assessed regularly for signs of infection (purulent drainage, erythema, warmth, pain, breakdown). Option 2: The nurse should never manipulate loose pins; contact the HCP. Option 3: Early ambulation should be promoted for patients with external fixation devices. Option 4: A neurovascular assessment should always be performed on limb surgeries or injuries. Check cap refill <3 seconds, sensation, ROM. Option 5: Pins should be cleaned with a sterile cleaning solution to prevent infection.

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply. 1. Confusion and restlessness 2. Increasing pain despite the opioid analgesia 3. Paresthesia of the affected extremity 4. Petechiae over neck and chest 5.Pulse oximeter showing hypoxia

1, 4, 5 FES is a rare complication that can occur due to a fracture of a long bone, pancreatitis, or liposuction and develops 24-72 hours after injury. The signs/symptoms are similar to that if an air emboli and cause vascular occlusion and affect respiratory status. Option 1: Confusion and restlessness are caused by neurologic changes due to hypoxia. Option 2: Increasing pain unrelieved by analgesics, or pain that is disproportionate to the injury, is a sign of compartment syndrome (pressure build up in a body compartment due to bleeding or swelling). Option 3: Paresthesia can also be a sign of compartment syndrome; a fat emboli may be asymptomatic until it reaches and occludes a vital artery. Option 4: Petechiae are caused by are caused by microvascular occlusion when the fat emboli blocks a vital artery. This does not occur with a pulmonary emboli. Option 5: Hypoxia (decreased O2 to tissues) occurs due to a fat emboli lodging in a pulmonary vessel and impairing gas exchange, causing dyspnea, tachypnea, and hypoxemia (low O2 in tissues).

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises

1, 4, 5 Option 1: Calcium and phosphorous give bones density and strength. Option 2: Bed rest decreases mechanical stress on bones, causing bone resorption and loss of bone desntiy. Option 3: Full bed rails increases the chance of falls and injury if the client tries to get out of bed during the night Option 4: Vitamin D is necessary for calcium absorption. Option 5: Weight-bearing exercises increase mechanical stress of bones, which increases bone density.

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply. 1. Cleans around the pin sites using sterile water 2. Gently tightens the device screws if they become loose 3. Holds the frame of the device when logrolling the client 4. Places a small pillow under the head when client is supine 5. Uses a blow-dryer on the cool setting to dry the vest when wet

1, 4, 5 Option 1: Using sterile technique will prevent infection. Option 2: The RN should never be tightening the pins; if they are loose, contact the HCP. Option 3: The nurse should avoid grabbing the device frame, as this can cause the screws to loosen or alter the alignment. Option 4: Clients with a halo external fixation device can place a small pillow under their head to reduce pressure on the device. Option 5: The vest liner should be changed weekly or when soiled, and can be dried with a blow dryer when wet.

The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1. Ask if the client wants pain medication for the "numbness and tingling" 2. Ask the client if the "numbness and tingling" were present before surgery 3. Continue assessment by observing the surgical dressing 4. Notify the health care provider (HCP) immediately

2 High glucose levels in blood can damage nerves over time. Diabetic neuropathy can cause numbness and tingling, especially in the lower extremities. Since pulses are strong bilaterally and capillary refill is sufficient, it's not likely to be anything more dangerous like a DVT.

The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which information should the nurse report to the health care provider (HCP) as soon as possible before the surgery? 1.Has allergy to strawberries 2.Is experiencing burning on urination starting yesterday 3.Rates knee pain as a 9 on a 0-10 scale 4.Stopped taking celecoxib 7 days ago

2 Option 1: A strawberry allergy won't affect surgery. An allergy to latex or antibiotics, however, should be reported to the HCP. Option 2: Burning with urination UTI; a contraindication to joint replacement surgery is pre-existing infections. Option 3: Severe knee pain is expected with a client undergoing a total joint replacement. Option 4: Celecoxib is an NSAID. Clients are directed to stop taking NSAIDs 7 days prior to surgery.

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? 1.Monitor gag and swallowing reflexes closely 2.Provide for client assistance with ambulation 3.Provide sensory stimulation 4.Speak at a normal volume while facing the client directly

2 The Romberg test is part of a neurological exam and assess the client's perception of their head in space (vestibular function) and body in space (proprioception). It is used to determine what is causing a loss in coordination (ataxia). Clients stand with feet together and eyes closed. If they lose their balance, it's a positive test result and indicates a sensory cause, not cerebellar. Option 1: Damage to the glossopharyngeal (IX) and vagus nerves (X) would cause swallowing and gag reflex problems. Option 2: Clients with a positive Romberg will have balancing issues. Option 3: A positive Romberg does not mean the client is disoriented or has altered LOC; sensory stimulation is not necessary. Option 4: Speaking at a normal volume while facing the client is used for people with hearing loss.

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching? 1."I have to give myself shots in the belly because my spouse is afraid of needles!" 2."I have to use a walker because I can't bear any weight on this knee yet." 3."I will call my health care provider if I get short of breath or sore or swollen below my knee." 4."The raised toilet seat makes it easier for me to get on and off the toilet by myself."

2 The average hospital length of stay following total knee arthroplasty is 3-5 days. After the surgery, immediate initiation of physical therapy is a priority. The client should be fully weight bearing by discharge.

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which client statements indicate a correct understanding of teaching? Select all that apply. 1."I should continue strenuous exercise during flare-ups." 2."I should include spine-stretching activities such as swimming." 3."I should quit smoking and perform breathing exercises." 4."I will sleep on a soft mattress to decrease my morning stiffness." 5."I will take the prescribed ibuprofen on an empty stomach."

2, 3 Ankylosing spondylitis is an inflammatory disease affecting the spine, with no known cause or cure. It causes stiffness, low back pain that resolves with activity, joint fusion, and spinal immobility. Option 1: It's best to rest during flare-ups under pain and inflammation are under control. Option 2: Exercises that extend the spine should be promoted, such as stretching, swimming, and tennis. Option 3: AS can limit chest wall expansion, so stopping smoking and performing breathing exercises can increase chest expand and reduce lung complications. Option 4: Soft mattresses cause spinal flexion, which can worsen the condition and cause deformity. Option 5: Ibuprofen should be taken with food to prevent gastric upset.

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply. 1. Apply heat to reduce swelling during the first 24 hours 2. Begin an exercise rehabilitation program when the pain subsides 3. Elevate the leg above the heart level on 2 pillows 4. Flex/dorsiflex the foot to prevent stiffness during the first 24 hrs 5. Take ibuprofen every 6 hours as needed 6. Wrap the ankle with an elastic compression bandage

2, 3, 5, 6 Option 1: Heat causes vasodilation and increases inflammation. Cold should be applied for 10-15 minutes for the first 48 hours to promote vasoconstriction and reduce swelling. Option 2: An exercise rehabilitation should begin ASAP (when pain subsides) to store ROM and strength. Option 3: Keeping the limb elevated reduces swelling Option 4: During the first 24-48 hours after an injury, rest and limited movement is recommended. Option 5: NSAIDs reduce swelling and pain. Option 6: Compression bandages promote venous return and prevent edema.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers 3. Elevate the arm on pillows above the level of the heart 4. Notify the health care provider 5. Reassure the client, document findings, and reassess in 1 hour

2, 4 Pain that is not relieved by analgesics, or disproportionate to the injury, may indicate compartment syndrome. Compartment syndrome is a complication that decreases blood flow distal to the injury from decrease compartment size (cast, splint) or increase pressure within (bleeding, inflammation). Option 1: Heat will increase inflammation of the site, and due to altered sensation, may cause burns. ROM may be contraindicated for that wrist after surgery. Option 2: The early symptoms of compartment syndrome include diminished pulses, pallor, coolness, swelling, and cyanosis. Option 3: If the only symptoms were pain and edema, and the distal extremity had feeling, no tingling, and was warm, then elevating the limb would be appropriate. Option 4: Compartment syndrome can cause loss of limb, and needs to be reported. Option 5: Not taking action can cause the patient to lose their limb. Any neurovascular changes always need to be assessed and reported.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? 1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor 2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

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The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching? 1. "Daily range-of-motion exercises are important to keep my joints flexible." 2. "I can use a moist heat pack to help with joint stiffness." 3. "I should elevate my knees with pillows when I'm sleeping." 4."I will make sure to rest in between activities throughout the day."

3 Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of contracture and may hasten decline of joint function.

A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for which finding is most important? 1. Biceps muscle spasm 2. Forearm swelling 3. Hand and wrist weakness 4. Shoulder range of motion

3 Crutches should be supported by the arms and hands, not the axillae (there should be 1-2" space between axilla and crutch pad). Pressure on the axilla that cause reversible nerve damage (crutch paralysis) that can cause muscle weakness, tingling, and numbness in the arms, wrists, and hands.

The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli? 1. Administering prophylactic enoxaparin as prescribed 2. Frequent use of incentive spirometry 3. Minimizing movement of the fractured extremity 4. Use of an intermittent pneumatic compression device

3 Fat embolism syndrome occurs when a long bone is fractured to the marrow and a fat globule is released, eventually blocking a crucial vessel in the brain, lungs, kidney, or small vessel and causing tissue ischemia. Option 1: Enoxaparin is an anticoagulant and prevent blood clot formation. It wouldn't help a fat emboli. Option 2: Incentive spirometry prevents atelectasis and pneumonia in clients who are not breathing deeply enough. Option 3: Minimizing movement of the affected limb can prevent a fat globule from leaking out. Option 4: A compression device would probably be contraindicated on a limb with a fractured bone. This would also only prevent a blood clot.

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most likely assess which of the following? 1. Complete stiffness of the shoulder joint 2. Paresthesia over the first 3½ fingers 3. Shoulder pain with arm abduction 4. Tenderness over the lateral epicondyle

3 Option 1: A completely stiff shoulder would be caused by a subluxation, dislocation, or a frozen shoulder (joint capsule becomes stiff/scar tissue formation). Option 2: Paresthesia indicates carpal tunnel or nerve damage. Option 3: Rotator cuff injury causes shoulder pain, which can be severe with hyperextension. Option 4: The rotator cuff is a group of muscles and tendons that surround the shoulder joint. The epicondyle is part of the elbow; tenderness there is seen with tennis elbow.

The nurse is caring for a client who is 12 hours postoperative total hip replacement. Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis? 1. Instructing the client to cross the legs only at the ankles 2. Maintaining the head of the bed at ≥60-90 degrees 3. Placing an abductor pillow between the legs when turning the client 4. Turning the client to the affected side to alleviate lateral muscle pulling

3 Option 1: The legs should never be crossed after a total hip replacement ever again. Option 2: The patient with a total hip replacement should never bend at the hip greater than 60 degrees. Option 3: A pillow or trochanter roll should be placed between the legs (from thighs to ankles) when rolling to keep the hips in abduction. Option 4: Turning the patient onto the operated side.

A client with rheumatoid arthritis (RA) tells the home health nurse, "My fatigue and stiffness are getting worse and I'm having trouble moving around, especially in the morning. What can I do?" Which intervention would be best for the client to perform first? 1.Eat a high-calorie carbohydrate breakfast immediately after awakening 2.Perform range of motion exercises before getting out of bed 3.Take a warm shower or bath immediately after getting out of bed 4.Take prescribed nonsteroidal anti-inflammatory medication on awakening

3 Prolonged morning stiffness is a common complication of rheumatoid arthritis. Option 1: A balanced diet and weight control can keep symptoms in check; not high carbs. Option 2: ROM exercises will help, but they will be more effective after a warm bath. Option 3: Heat decreases stiffness and promotes muscle relaxation and mobility. Option 4: NSAIDs should not be taken on an empty stomach.

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask? 1. "Have the assistive devices helped with dressing and grooming?" 2. "How do you feel about the changes in your appearance?" 3. "How is your pain control with the current medication regimen?" 4. "Is your level of energy adequate for completing your daily activities?"

3 RA is an autoimmune disorder that affects joints and causes inflammation and eventual joint deformities with decreased or absent range of motion and loss of function. Clients become easily fatigued and must learn to pace themselves and use assistive devices to accomplish activities of daily living. Follow Maslow's hierarchy: pain (physiological) is more important that the other options, which focus on esteem and comfort.

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG 2. IV morphine 2 mg 3. Normal saline bolus 4. Urine sample

3 Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. Option 1: ECG and cardiac monitoring are needed, as muscle damages causes potassium to be released and hyperkalemia can occur, but treatment is the priority over testing or observation. Options 2, 4: Pain, symptom management, and testing do not take priority over treatment. Option 3: The nurse's priority is to prevent kidney damage by rapidly infusing fluid to flush out the myoglobin from the body.

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching? 1. "Even with appropriate treatment, joint damage and disability are inevitable." 2. "My arthritis can be resolved if I can improve my diet and lose weight." 3. "My methotrexate should be taken even when my joints aren't hurting." 4. "When my joints hurt, I should rest frequently and try not to move them."

3 Rheumatoid arthritis is a chronic, autoimmune disorder in which synovial joints become inflamed and fibrosed, leading to stiffening, ligament contracture, and joint deformities. Option 1: Body aligners and immobilizers should be used when resting to prevent joint deformity as much as possible. Option 2: RA can never be cured, just treated. Weight loss can prevent mechanical erosion, which can prevent exacerbation of RA. Option 3: RA is treated with drugs known as Disease-Modifying Antirheumatic Drugs (DMARDs) and should be taken regardless of symptoms. Option 4: Unless a flare up is particularly painful, ROM exercises should always be completed.

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action? 1. Administer analgesia 2. Apply an ice pack to the wrist 3. Assess capillary refill and sensation 4. Elevate the wrist above heart level

3 With any limb injury, a neurovascular assessment should always be completed prior to any intervention. The swelling and severe pain could be due to compartment syndrome or nerve damage.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1.Ask another nurse to help 2.Delegate the task to unlicensed assistive personnel 3.Premedicate the client for pain 4.Verify the client's activity prescription

4

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan? 1.Apply elastic compression hose to wrists 2.Avoid use of caffeinated or tobacco products 3.Perform repetitive hand exercises daily 4.Wear a wrist immobilization splint

4 Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by median nerve compression within the carpal tunnel at the wrist. Nerve compression can occur due to inflammation of the tendons; narrowing or compression of the carpal tunnel; or wrist flexion or extension. Option 1: Compressing the wrist increases nerve compression, making it worse. Option 2: Avoidance of caffeine and tobacco would not affect CTS. Option 3: Repetitive hand movement can cause CTS, so this will make it worse. Option 4: Immobilizing the joint reduces pain and prevents flexion and extension, which decreases compression on the nerve.

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action? 1. Cut the wires 2. Elevate the head of the bed 3. Notify the health care provider 4. Suction the mouth and oropharynx

4 Clearing the airway is the most crucial action that needs to be completed first. If the suction does not adequately clear the airway, then cutting the wires can be done. This is not the first action, because it can take some time to cut the wires.

The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action? 1. Blood-tinged stain on the inner aspect of the cast 2. Capillary refill of 2 seconds on the affected extremity 3. Mild swelling of toes on the right foot 4. Pain of 9/10 an hour after a dose of morphine

4 Neurovascular integrity should always be tested before/after cast application: circulation, motor, and sensory checks. There should be no numbness or tingling. Option 1: The patient is post-op, so bleeding is expected. The nurse should circle the blood stains and mark the date/time to visualize any further bleeding. Option 2: A cap refill should be <3 seconds. The color and temperature should also be assessed (should be pink and warm). Option 3: The pressure of the cast can cause mild swelling/edema. Elevating the affected leg can alleve swelling. Report any increases in swelling or severe pain Option 4: Severe pain that does not decrease after a strong analgesic, or is disproportionate to the injury, indicates compartment syndrome. Compartment syndrome occurs when there is increased swelling/pressure within the limb and there is no longer adequate blood/O2 perfusion.

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1. "I will hold the cane in my right hand." 2. "I will move my left leg forward after moving the cane." 3. "I will place the cane several inches in front of and to the side of my right foot." 4. "My cane should equal the distance from my waist to the floor."

4 Option 1: A cane should be held on the stronger, unaffected side. Options 2, 3: When walking, the left leg should never move any further out than the cane to maximum stability; 2 points of support should always be on the floor at all times. Option 4: The can should equal the distance from the client's greater trochanter to the floor. Incorrect cane length can cause back injury.

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first? 1. Client who sustained a closed, incomplete ulnar fracture while playing sports 2. Client with bilateral metacarpal fractures after falling out of bed 3. Client with multiple myeloma who has a vertebral fracture and aching back pain 4. Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation

4 Option 1: Greenstick fractures (bone bends and cracks, but remains in one piece) are most common in children. Option 2: Fractures in the bones of the hand are common in fall injuries. Option 3: Multiple myeloma (type of WBC cancer in bone marrow) weakens bones, and vertebrae fractures are common. This client is second to be assessed, due to the risk of spinal cord injury. Option 4: Pins and needles sensation indicates a potential neurovascular injury; neurovascular injuries should always be assessed first. Joint dislocations can be emergencies, because the articular bone may compress surrounding vasculature, causing distal ischemia and potential loss of limb.

The nurse receives laboratory reports on 4 clients. Which report is most concerning and should be reported to the health care provider? 1. The client admitted with asthma exacerbation who has a PaCO2 of 32 mm Hg 2. The client diagnosed with COPD whose latest arterial blood gas shows a PaO2 of 85 mm Hg 3. The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5 4. The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL

4 Option 1: Normal PaCO2 is 35-45 mmHg. Option 2: Normal PaO2 is 80-100 mmHg (as opposed to SaO2/pulse oximetry, which is 90-100 mmHg). In patients with COPD, it is normal to have a lower PaO2 >60 mmHg (SaO2 >80 mmHg) with no exacerbations. Their body has adjusted to the higher CO2 level, and increasing oxygen may hinder their respiratory drive. Option 3: An INR of 2-3 is normal when on anticoagulant therapy (if not on therapy, <1 is normal). Option 4: Normal Hgb is 14-18 g/L (men) and 12-16 g/L (women). A complication of a total knee replacement is blood loss. This lab value is significantly low and needs to be reported. Other symptoms the patient may have due to blood loss may be: rapid pulse, SOB, low BP

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to assess? 1. Asymmetrical pain in the large weight bearing joints 2. Low back pain and stiffness that is worse in the morning 3. Pain, swelling, and redness of the great toe 4. Symmetrical pain and swelling in the small joints of the hands

4 Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disorder that has periods of exacerbations and remissions. The body attacks the lining of the joints, causing bone erosion and deformity. Option 1: RA pain is symmetrical. Asymmetrical pain may be due to osteoarthritis or carpal tunnel. Option 2: RA doesn't usually affect the spine, although it can cause morning joint pain and stiffness that can last for 60 minutes after waking. Option 3: Pain, redness, and welling of extremity joint (especially a big toe) is indicative of an acute gout attack, a form of arthritis in which excess uric acid crystallizes and deposits in a joint. Option 4: RA typically affects the small joints of the hands and feet.

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan? 1. Apply body lotion or powder under the brace to prevent skin irritation 2. Avoid any exercises that require the use of spinal muscles 3. Keep the brace on for all activities, including showering 4. Wear a cotton t-shirt under the brace at all times

4 The Boston brace is used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. It is molded to be worn over clothing. Option 1: Using lotion or powder underneath can cause skin irritation Option 2: The brace should be removed during exercise, as this maintains and promotes spinal muscle strength. Option 3: The brace should be removed for bathing. Option 4: The brace is meant to be worn under clothing to prevent skin breakdown, decrease skin irritation, and absorb sweat.

A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention? 1. Administer nasal oxygen at 3 L/min 2. Administer opioids for pain 3. Apply ice pack to face for 20 minutes each hour 4. Suction the mouth and oropharynx

4 The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway and lead to aspiration.

The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's priority action? 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check of the casted extremity 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch 4. Review appropriate itch relief technique using the cool setting of a hair dryer

4 To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the cast. Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, injury, or infection may occur.