MS2- Musculoskeletal- NCLEX-RN Book
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? A. Clear mentation B. Minimal dyspnea C. Oxygen saturation of 85% D. Arterial oxygen level of 78 mm Hg (10.3 kPa)
ANS: A 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 being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? A. "I need to avoid getting the cast wet." B. "I need to cover the casted leg with warm blankets." C. "I need to use my fingertips to life and move my leg." D. "I need to use something like a padded coat hanger end to scrach under the cast if it itches."
ANS: A Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.
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. A. Keep the cast clean and dry. B. Allow the cast 24 to 72 hours to dry. C. Keep the cast and extremity elevated. D. Expect tingling and numbness in the extremity. E. Use a hair dryer set on a warm to hot setting to dry the cast. F. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.
ANS: A, B, C 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 has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. A. "I should not use someone else's crutches." B. "I need to remove any scatter rugs at home." C. "I can use crutch tips even when they are wet." D. "I need to have spare crutches and tips available." E. "When I'm using the crutches, my arms need to be completely straight."
ANS: A, B, D 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.
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? A. A fall and further injury B. Injury to the brachial plexus nerves C. Skin breakdown in the area of the axilla D. Impaired range of motion while the client ambulates
ANS: B Rationale: Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.
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? A. Cold, bluish-colored fingers B. Numbness and tingling in the fingers C. Pain that increases when the arm is dependent D. Pain that is out of proportion to the severity of the fracture
ANS: B 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 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? A. Apply ice to the site. B. Call the health care provider (HCP). C. Rewrap the residual limb with an elastic compression bandage. D. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.
ANS: C 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.
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? A. Infection under the cast B. The anxiety of the client C. Impaired tissue perfusion D. The recent occurrence of the fracture
ANS: C 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 assessing the casted extremity of a client. Which sign is indicative of infection? A. Dependent edema B. Diminished distal pulse C. Presence of a "hot spot"on the cast D. Coolness and pallor of the extremity
ANS: C Rationale: Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.
The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be MOST concerned with which finding? A. Redness around the pin sites B. Pain on palpation at the pin sites C. Thick, yellow drainage from the pin sites D. Clear, watery drainage from the pin sites
ANS: C Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.
The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? A. Elevated for 3 hours, then flat for 1 hour B. Flat for 3 hours, then elevated for 1 hour C. Flat for 12 hours, then elevated for 12 hours D. Elevated on pillows continuously for 24 to 48 hours.
ANS: D Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? A. "I can resume regular exercise tomorrow." B. "I can't eat food for the remainder of the day." C. "I need to stay off the leg entirely for the rest of the day." D. "I need to report a fever or swelling to my health care provider."
ANS: D Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider.
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? A. Hemorrhage B. Edema of the residual limb C. Slight redness of the incision D. Separation of the wound edges
ANS: D 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 is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? A. A 25-year-old woman who runs B. A 36-year-old man who has asthma C. A 70-year-old man who consumes excess alcohol.
ANS: D Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.
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? A. Try to reduce the fracture manually. B. Assist the victim to get up and walk to the sidewalk. C. Leave the victim for a few moments to call an ambulance. D. Stay with the victim and encourage him or her to remain still.
ANS: D 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.