NCLEX 7th Ed Musculoskeletal

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

"I need to avoid getting the cast wet."

The nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a need for further teaching?

"I'll be careful not to lift anything heavier than 20 pounds."

The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?

"I'll report fever or site inflammation to the primary health care provider."

The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?

"I'm doing these exercises so I can begin to fasten my buttons and dress myself again."

The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?

"If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Rationale: The client needs further teaching if the client states that if the cast gets wet, drying it with a hair dryer turned to the warmest setting is an option. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown.

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement?

"It is a normal response and indicates the presence of phantom limb sensation."

The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a need for further teaching?

"This condition is primarily due to my lack of calcium and testosterone."

The nurse is caring for a client with osteoporosis who is being discharged with instructions to take calcium with vitamin D. Which instructions should the nurse give the client about taking this medication? Select all that apply.

- "Take a third of the daily dose at bedtime." - "Increase fluid intake, unless medically contraindicated." -"Take the medication with 6 to 8 ounces of water to help dissolve it."

The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply.

- Bony deformity - Limited joint mobility - Peripheral neuropathy -Peripheral vascular disease -History of skin ulcers or previous amputation

The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? Select all that apply.

- Drink plenty of fluids. - Avoid taking diuretics. - Avoid excessive physical or emotional stress.

The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply.

- Dyspnea - Hypoxemia - Tachypnea

The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply.Ensure that the machine is well padded. 2.Assess the client's response to the machine.

- Ensure that the machine is well padded. - Assess the client's response to the machine. - Turn off the machine while the client is having a meal in bed. - Make sure that the joint being moved is properly positioned on the machine.

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply.

- Femur - Skull -Tibia - Vertebrae

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply.

- Keep the cast and extremity elevated. - The cast needs to be kept clean and dry. - Allow the wet cast 24 to 72 hours to dry.

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

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

The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast?

A hip spica cast

A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement?

Administer an analgesic.

The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client?

Administering intramuscular opioid analgesics Rationale: Administering intramuscular opioid analgesics to a client following a bone biopsy is an unnecessary action for the nurse. Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema.

The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding?

An oral temperature of 101° F orally

The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?

Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse should be most useful in trying to provide good skin care to the client?

Asking the client to pull up on a trapeze to lift the hips off the bed

A client is complaining of low back pain with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?

Bending or lifting

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

C

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus?

Clear chest x-ray

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?

Concerns about body image

The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder?

Dull aching pain in the affected joints

The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?

Elevating the limb and applying ice to the affected leg

The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which action should be done?

Get out of bed by sitting straight up and swinging the legs over the side of the bed. Rationale: The client needs further teaching if the client says sitting straight up and swinging the legs over the side is the way to get out of bed. Clients are taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed, using one or both arms. The back is kept straight, and the legs are swung over the side.

The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client?

Increasingly vigorous and high-impact exercise

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

Leakage of clear fluid from the nose Rationale: When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF.

A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane?

Left hand, and 6 inches lateral to the left foot

The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?

Maintaining body weight at or above minimum recommended levels

A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?

Moist, sterile saline dressings

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?

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

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next?

Notify the registered nurse.

The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate?

Petal the cast edges with adhesive tape.

The nurse is preparing a plan of care for a client in skeletal leg traction with an over bed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed?

Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?

Pork

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection?

Presence of a "hot spot" on the cast Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others.

The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action?

Rewrap the residual limb with an elastic compression bandage.

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

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

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?

Showing the client the cast cutter and explaining how it works

A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction?

Slightly elevating the foot of the bed Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated.

The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action?

Stay with the victim.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?

The client advances the walker with reciprocal motion.

The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data should be included?

The client's vital signs, muscle strength, and previous activity level

The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?

The device is applied before getting out of bed in the morning.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick, yellow drainage from the pin sites

The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?

"Crutch tips will not slip, even when wet."

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement?

"I need to scrub the skin vigorously with soap and water." Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied.

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Bleeding and swelling cause increased pressure in an area that cannot expand.

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device?

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

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

Petaling the cast edges with adhesive tape

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?

Pillow to keep the right leg abducted during turning

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching?

"I'm glad I can still drink as much coffee as I want." Rationale: There is a need for further teaching when a client with osteoporosis says "I'm glad I can still drink as much coffee as I want." The nurse needs to teach clients to avoid excessive alcohol and caffeine consumption and about the need for adequate amounts of calcium and vitamin D for bone remodeling.

A client with possible rib fracture has never had a chest x-ray. The nurse should tell the client which statement about the procedure?

"It is necessary to remove jewelry and any other metal objects." Rationale: An x-ray is a photographic image of a part of the body on a special film that is used to diagnose a wide variety of conditions. The x-ray itself is painless. Any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain.

The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan?

"Lift the left arm up over the head." Rationale: The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The use of slings further immobilizes the shoulder and may be contraindicated.

The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching?

"My crutches must rest up underneath my arm for extra support."

The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply.

- Ensure the client doesn't sit or stand for long periods of time. - Ensure the client doesn't cross the legs past the midline of the body. - Ensure the client uses assistive/adaptive devices with activities of daily living.

An elderly client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? Select all that apply.

- Osteoporosis - Foot disorders -Bony metastases - Changes in cardiac function

The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which issues could place the client at increased risk for disturbed thought processes? Select all that apply.

- Stress from the fracture - Eyeglasses left at home Unfamiliar hospital setting -Side effects of medications

The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? Select all that apply.

- Use a shrinker stocking or sock to cover the wrapped stump. - Begin residual limb care when sutures or staples are removed. - After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. - When the staples or sutures are removed, inspect the end of the residual limb every day for signs of inflammation or skin breakdown

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?

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

The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room?

Anesthesia consent Rationale: The item that is least likely needed before reduction of a fracture in the casting room is an anesthesia consent. Before a fracture is reduced, the client is informed about the procedure and consent is obtained.

A client is treated in the primary health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours?

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

The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first?

Check the client's alignment in bed. Rationale: A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait.

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?

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

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which action to maintain client safety after this procedure?

Having the client use an overhead trapeze

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor?

High-calcium diet consumption Rationale: The nursing student needs further teaching if the student states that a high-calcium diet is an associated risk factor of osteoporosis. Risk factors associated with osteoporosis include a diet that is deficient in calcium.

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority?

Immobilize the leg before moving the client. Rationale: When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client.

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

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

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?

In semi-Fowler's position with the knee gatch slightly raised

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown?

Left heel 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.

A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason?

Muscle spasm in the area of the herniated disk

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action?

Notify the registered nurse. Rationale:The client with pallor, slow capillary refill, weakened or lost pulse, and absence of sensation or motion to the distal limb may have arterial damage from a lacerated, contused, thrombosed, or severed artery. Regardless of the cause, the LPN notifies the registered nurse immediately, who will contact the primary health care provider.

The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?

Numbness and tingling in the fingers

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?

Performing active range of motion (ROM) to the right ankle and knee Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises).

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function?

Provides comfort by reducing muscle spasms and provides fracture immobilization

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?

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

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What should the nurse tell the client to provide greater reassurance?

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

The nurse is teaching a client how to walk with a cane. Which information should the nurse include? Select all that apply.

The cane should create no more than 30 degrees of flexion of the elbow. The top of the cane should be parallel to the greater trochanter of the femur. A straight leg cane is used if the client only needs minimal support for an affected leg.

The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting?

The client may bear weight on the cast in 30 minutes. Rationale: The client needs further teaching about plaster casts if the client plans to bear weight on the cast in 30 minutes. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question?

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