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Nclex-PN Musculoskeletal Exam With Questions And Answers
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Nclex-PN Musculoskeletal Exam With Questions And Answers 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 appe ars fractured. The nurse should plan to perform which action? 1.Try to manually reduce the fracture. 2.Assist the person with getting up and walking to the sidewalk. 3.Leave the person for a few moments to call an ambulance. 4.Stay with the person and encourage the person to remain still. - Answer4 (Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remai n 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.) The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the *priority*? 1.Take a set of vital signs. 2.Call the radiology department. 3.Immobilize the leg before moving the client. 4.Reassure the client that everything will be fine. - Answer3 (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. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.) 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? 1.Allows bony healing to begin before surgery 2.Provides rigid immobilization of the fracture site 3.Lengthens the fractured leg to prevent severing of blood vessels 4.Provides comfort by reducing muscle spasms and provides fracture immobilization - Answer4 (Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, befo re the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.) (Test-Taking Strategy(ies): Note the strategic word, primary, and focus on the subject, the function of Buck's extension traction. Recalling the purpose of traction will assist in elimina ting options 1 and 3. From the remaining options, eliminate the option with the words rigid immobilization.) The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1.Inflammation 2.Serous drainage 3.Pain at a pin site 4.Purulent drainage - Answer2 (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 expect ed findings and should be reported.) The nurse is caring for the client who has had skeletal traction applied to t he left leg. The client is complaining of severe left leg pain. Which action should the nurse take *fi rst*? 1.Provide pin care. 2.Check the client's alignment in bed. 3.Medicate the client with an analgesic. 4.Call the primary health care provider (PHCP). - Answer2 (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 i neffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the caus e. Providing pin care is unrelated to the problem as described.) 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? 1.Pulling up on the trapeze 2.Flexing and extending the feet 3.Doing quadriceps-setting and gluteal-setting exercises 4.Performing active range of motion (ROM) to the right ankle and knee - Answ er4 (Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintai n muscle strength and ROM. The client may pull up on the trapeze, perform active RO M with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful.) The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1.Dependent edema 2.Diminished distal pulse 3.Presence of a "hot spot" on the cast 4.Coolness and pallor of the extremity - Answer3 (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 PHCP should be notified if any of these occur. Signs of impair ed circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.) A client has sustained a closed fracture and has just had a cast applied to the affec ted arm. The client is complaining of intense pain. The nurse has elevated the limb, app lied 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? 1.Infection under the cast 2.The anxiety of the client 3.Impaired tissue perfusion 4.The newness of the fracture - Answer3 (Rationale: Most pain associated with fractures can be minimized with rest, elevation, ap plication 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 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. I n positioning the casted leg, the nurse should perform which intervention? 1.Keep the leg in a level position. 2.Elevate the leg for 3 hours, and put it flat for 1 hour. 3.Keep the leg level for 3 hours, and elevate it for 1 hour. 4.Elevate the leg on pillows continuously for 24 to 48 hours. - Answer4 (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 is complaining of skin irritation from the edges of a cast applied t he previous day. The nurse should plan for which intervention? 1.Massaging the skin at the rim of the cast 2.Petaling the cast edges with adhesive tape 3.Using a rough file to smooth the cast edges 4.Applying lotion to the skin at the rim of the cast - Answer2 (Rationale: The edges of the cast can be petaled with tape to minimize skin irritat ion. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast.) The nurse is preparing a list of cast care instructions for a client who just ha d a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? *Select all that apply.*The benefits of buying summaries with Stuvia:
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