Nursing Skills I Q&A | Nursing
1. Which of the following is the primary focus of a musculoskeletal physical
assessment?
A) Evaluating pain, swelling, range of motion, and function
B) Measuring vital signs and auscultating breath sounds
C) Assessing skin integrity and capillary refill
D) Evaluating cranial nerve function and reflexes
Correct Answer: Evaluating pain, swelling, range of motion, and function
Rationale: The primary focus of a musculoskeletal assessment is to evaluate
pain, swelling, range of motion, and function. This helps identify the extent of
injury or dysfunction. While vital signs, skin assessment, and neurological
assessment are important, they are not the primary focus of a
musculoskeletal exam.
2. A client reports severe pain, swelling, and an inability to move the right
arm after a fall. The nurse should anticipate which diagnostic test first?
A) Magnetic resonance imaging (MRI)
B) Computed tomography (CT) scan
C) X-ray
D) Bone scan
Correct Answer: X-ray
Rationale: An X-ray is the initial diagnostic test for suspected fractures, as it
provides a clear image of bone structure and can identify breaks or
dislocations. MRI and CT scans provide more detail but are not the first-line
,imaging for trauma. Bone scans are used for detecting bone infections or
tumors.
3. A nurse is caring for a client in skeletal traction. Which nursing
intervention is most important to prevent complications?
A) Ensure the traction weights are resting on the floor
B) Check the pin sites for signs of infection daily
C) Remove the traction for 30 minutes each shift
D) Position the client with the hips flexed at 90 degrees
Correct Answer: Check the pin sites for signs of infection daily
Rationale: Skeletal traction involves pins inserted into the bone, which
creates a direct portal for infection. The nurse should assess pin sites daily
for redness, swelling, drainage, and odor. The weights should hang freely,
not rest on the floor, and traction should never be removed without a
provider's order.
4. A client has a new cast applied to the lower leg. Which assessment finding
should the nurse report to the provider immediately?
A) Capillary refill of 2 seconds
B) The client reports a pins-and-needles sensation in the toes
C) Mild swelling of the toes
D) The cast feels warm to the touch
Correct Answer: The client reports a pins-and-needles sensation in the toes
Rationale: Paresthesia (pins-and-needles sensation) in the extremity distal to
a cast may indicate compartment syndrome or nerve compression, which is
a medical emergency. Capillary refill of 2 seconds and mild swelling are
,expected findings. A warm cast indicates the cast is drying and is a normal
finding.
5. A nurse is assessing a client who has sustained a fracture. Which finding is
most indicative of compartment syndrome?
A) Pain that is relieved by elevation
B) Pain that is unrelieved by opioid analgesics
C) Bounding peripheral pulses
D) Warm, dry skin distal to the injury
Correct Answer: Pain that is unrelieved by opioid analgesics
Rationale: Compartment syndrome is characterized by severe pain that is not
relieved by opioid analgesics and is out of proportion to the injury. Other
signs include pallor, pulselessness, paresthesia, and paralysis (the "5 P's").
Pain that is relieved by elevation is not typical of compartment syndrome.
6. A client with a fractured femur develops sudden shortness of breath, chest
pain, and petechiae on the chest. The nurse should suspect which
complication?
A) Pneumonia
B) Pulmonary embolism
C) Fat embolism syndrome
D) Atelectasis
Correct Answer: Fat embolism syndrome
Rationale: Fat embolism syndrome is a complication of long bone fractures
(e.g., femur) in which fat globules enter the bloodstream and lodge in the
pulmonary capillaries. Symptoms include sudden shortness of breath, chest
, pain, petechiae, and neurological changes. Pulmonary embolism is a possible
complication but is more commonly associated with DVT.
7. A client is 24 hours post-operative following a total hip replacement.
Which position should the nurse avoid?
A) Adduction of the operative leg
B) Abduction of the operative leg
C) Extension of the operative leg
D) Flexion of the operative leg to 45 degrees
Correct Answer: Adduction of the operative leg
Rationale: After a total hip replacement, the operative leg should be kept in
abduction (not adduction) to prevent dislocation of the prosthesis. The leg
should also not be flexed beyond 90 degrees. Adduction (crossing the legs)
places the hip at risk for dislocation.
8. A nurse is teaching a client with osteoarthritis about managing the
condition. Which statement by the client indicates understanding?
A) "I should limit my activity to prevent further joint damage."
B) "I can take ibuprofen as needed for joint pain and stiffness."
C) "I should apply heat to acutely inflamed joints."
D) "I should avoid all weight-bearing exercises."
Correct Answer: "I can take ibuprofen as needed for joint pain and stiffness."
Rationale: Osteoarthritis is managed with NSAIDs (e.g., ibuprofen) for pain
and inflammation. Clients should engage in regular, low-impact exercise to
maintain joint function. Heat is used for chronic stiffness, while cold is
applied to acutely inflamed joints.