NCLEX PN Musculoskeletal Exam with Questions and Answers with Rationales Latest Update 2025 Rated A+

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? 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. - 4 (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.) 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. - 3 (Rationale: NCLEX PN Musculoskeletal Exam with Questions and Answers with Rationales Latest Update 2025 Rated A+ 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 - 4 (Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, before 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 eliminating 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 - 2 (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.) 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*? 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). - 2 (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. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. 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 - 4 (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). 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 - 3 (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 impaired 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 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? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The newness of the fracture - 3 (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 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? 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. - 4 (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 the 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 - 2 (Rationale: The edges of the cast can be petaled with tape to minimize skin irritation. 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 had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? *Select all that apply.* 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft-padded object that will fit under the cast to scratch the skin under the cast. - 1, 2, 3 (Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands 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 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 PHCP is notified immediately if circulatory impairment occurs.) 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? 1. 3 inches to the front and side of the client's toes 2. 8 inches to the front and side of the client's toes 3. 15 inches to the front and side of the client's toes 4. 20 inches to the front and side of the client's toes - 2 (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 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 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches out to the side of the right foot - 2 (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 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? 1. Elevating the limb and applying ice to the affected leg 2. Elevating the limb and covering it with bath blankets 3. Keeping the leg horizontal and applying ice to the affected leg 4. Placing the leg in a slightly dependent position and applying ice - 1 (Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect.) 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? 1. "I need to avoid getting the cast wet." 2. "I will use my fingertips to lift and move the leg." 3. "I need to cover the casted leg with warm blankets." 4. "I can use a padded coat hanger end to scratch under the cast." - 1 (Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. 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; a cool hair dryer may be used to eliminate itching.) 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? 1. "I will soak the skin and then wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if it will be directly exposed to the sun." - 2 (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. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid direct exposure of the skin to the sunlight.) 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? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head - 2 (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 has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed - 3 (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. Option 1 places undue pressure on the client's unaffected foot. Option 2 is not used for the purpose of countertraction. Buck's extension traction is applied to the leg, so you can eliminate option 4.) 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.* 1. Psoriasis 2. Bony deformity 3. Limited joint mobility 4. Peripheral neuropathy 5. Peripheral vascular disease 6. History of skin ulcers or previous amputation - 2,3,4,5,6 (Rationale: Certain conditions place clients with diabetes at increased risk for amputation. These factors include peripheral neuropathy, limited joint mobility, bony deformity, peripheral vascular disease, and a history of skin ulcers or previous amputation. The nurse needs to observe for changes that indicate peripheral neuropathy or vascular insufficiency.) 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? 1. "It is a normal response and indicates the presence of phantom limb pain." 2. "It is a normal response and indicates the presence of phantom limb sensation." 3. "It is an abnormal response and indicates that the client is in denial about the limb loss." 4. "It is an abnormal response and indicates that the client needs more psychological support." - 2 (Rationale: Phantom limb sensations felt in the area of the amputated limb indicate a normal response. These can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, called "phantom limb pain." The origin of the pain is less well understood, but the client should also be prepared for this whenever possible.) 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? 1. Increase fiber and fluids in the diet. 2. Bend at the knees to pick up objects. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed. - 4 (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. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects.) 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? 1. Administer an analgesic. 2. Notify the registered nurse. 3. Check the circulation again in 30 minutes. 4. Provide range-of-motion exercises to the fingers of the left hand. - 2 (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. These signs can occur with constriction from a tight cast as well. Emergency intervention is needed, which could include removal of the constricting bandage, fracture reduction, or surgery to repair the area.) A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 1. The cast will be bivalved. 2. A window will be cut in the cast. 3. The cast will be replaced with an air splint. 4. Extra padding will be put over this area of the cast. - 2 (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 use of an air splint is not indicated.) 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? 1. Postmenopausal age 2. Family history of osteoporosis 3. High-calcium diet consumption 4. Long-term use of corticosteroids - 3 (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. Postmenopausal age, family history, and long- term use of corticosteroids are risk factors associated with osteoporosis. Additional risk factors include being sedentary, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide.) 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? 1. Pork 2. Seafood 3. Sardines 4. Plain yogurt - 1 (Rationale: Of the items listed, pork would contain the least amount of calcium.) The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 1. Morning stiffness 2. Positive rheumatoid factor 3. An elevated sedimentation rate 4. Dull aching pain in the affected joints - 4 (Rationale: The sign/symptom associated with osteoarthritis is dull, aching pain that occurs in the affected joints. Unlike rheumatoid arthritis, systemic manifestations are absent and joint involvement is not symmetrical. The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify after activity, and they may be aggravated by cold, damp weather. No specific laboratory findings are useful in diagnosing osteoarthritis. Morning stiffness, an elevated sedimentation rate, and a positive rheumatoid factor occur in rheumatoid arthritis.) 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? 1. Resting the foot 2. Applying an Ace wrap 3. Applying a heating pad 4. Elevating the ankle on a pillow while sitting or lying down - 3 (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 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? 1. "I can resume regular exercise tomorrow." 2. "I will stay off of the leg entirely for the rest of the day." 3. "I need to refrain from eating food for the remainder of the day." 4. "I'll report fever or site inflammation to the primary health care provider." - 4 Rationale: The client understands the discharge instructions after a knee arthroscopy if the client plans to report any fever or site inflammation to the primary health care provider. Any signs/symptoms of infection must be reported to the primary health care provider. After arthroscopy the client can usually 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.) 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.* 1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living. - 2,4,5 (Rationale: The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend his/her hips beyond 90 degrees and not 120 degrees, doesn't sit or stand for long periods of time, and doesn't cross his/her legs past the midline of the body. The nurse should ensure that the client engages in walking and mild, not rigorous, exercise to maintain strength and that the client uses assistive/adaptive devices when performing activities of daily living.) 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? - 1 (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. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture.) 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*? 1. "I will avoid excessive amounts of alcohol." 2. "I'm glad I can still drink as much coffee as I want." 3. "I must make sure I include fruits and vegetables in my daily diet." 4. "I need to make sure I have adequate amounts of calcium and vitamin D." - 2 (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. The nutritional considerations for the treatment of a client with a diagnosis of osteoporosis are the same as those for preventing the disease. The nurse needs to help the client develop a nutritional plan that is most beneficial in maintaining bone health. The plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine.) 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? 1. Elevating the limb for 24 hours 2. Monitoring vital signs every 4 hours 3. Administering intramuscular opioid analgesics 4. Monitoring the site for swelling, bleeding, hematoma - 3 (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 vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.) A client with possible rib fracture has never had a chest x-ray. The nurse should tell the client which statement about the procedure? 1. "The x-ray stimulates a small amount of pain." 2. "It is necessary to remove jewelry and any other metal objects." 3. "The client will be asked to breathe in and out during the x-ray." 4. "The x-ray technologist will stand next to the client during the x-ray." - 2 (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. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area.) 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.* 1. Fever 2. Dyspnea 3. Petechiae 4. Hypoxemia 5. Tachypnea 6. Decreased level of consciousness - 2, 4, 5 (Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop.) 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? 1. Anesthesia consent 2. Consent for the procedure 3. Administration of an analgesic 4. Explanation of the procedure to the client - 1 (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. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room.) 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? 1. The cast will give off heat as it dries. 2. The cast edges may be trimmed with a cast knife. 3. The client may bear weight on the cast in 30 minutes. 4. A stockinette will be placed over the leg area to be casted. - 3 (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. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries.) 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? 1. "Use a sling on the left arm." 2. "Lift the left arm up over the head." 3. "Lift the right arm up over the head." 4. "Make a fist with the hand of the casted arm." - 2 (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. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.) 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? 1. In 24 hours 2. In 48 hours 3. In approximately 8 hours 4. Within 20 to 30 minutes of application - 4 (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.) 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? 1. "I should avoid walking on wet, slippery floors." 2. "I'm not supposed to scratch the skin underneath the cast." 3. "It's all right to wipe dirt off the top of the cast with a damp cloth." 4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." - 4 (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. Client instructions should include avoidance of walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation.) 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? 1. Having another nurse tilt the client to the side 2. Asking the client to pull up on a trapeze to lift the hips off the bed 3. Pushing down on the mattress of the bed while administering care 4. Asking the client to lift up by digging into the mattress with the unaffected leg - 2 (Rationale: The nursing action that would be most useful if the client in skeletal traction may not turn from side to side is to have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other.) A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1. Giving pin care once a shift 2. Massaging the skin of the right leg with lotion every 8 hours 3. Inspecting the skin on the right leg at least once every 8 hours 4. Releasing the weights on the right leg for range-of-motion exercises daily - 3 (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.) The nurse is teaching a client about crutch walking. Which comment by the client indicates a *need for further teaching*? 1. "I know I need strong arm muscles to walk with crutches." 2. "My crutches must rest up underneath my arm for extra support." 3. "I need to make sure that there are rubber tips on the ends of my crutches so I won't slip." 4. "I'm going to use the three-point gait, because it allows little weight bearing on my affected leg." - 2 (Rationale: There is a need for further teaching when the client states that crutches need to rest up underneath the arm. Crutches must not rest underneath the client's arm, because it could cause injury to the nerves of the brachial plexus. Crutches must be measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body.) 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? 1. Crutches and then both legs simultaneously 2. Crutches and the right leg, then advance the left leg 3. Crutches and the left leg, then advance the right leg 4. Left leg and right crutch, then right leg and left crutch - 2 (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. Putting the crutches and the right leg down, then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then right leg and left crutch down describes a two-point gait.) The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a *need for further teaching*? 1. "Crutch tips will not slip, even when wet." 2. "Use of someone else's crutches is a bad idea." 3. "Crutch tips should be inspected periodically for wear." 4. "I need to have spare crutches and tips available." - 1 (Rationale: There is a need for further teaching when the client says that crutch tips won't slip even when wet. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed) The nurse is teaching a client how to walk with a cane. Which information should the nurse include? *Select all that apply.* 1. The cane is placed on the affected side. 2. A quad-cane provides a narrower base for the cane. 3. The cane should create no more than 30 degrees of flexion of the elbow. 4. The top of the cane should be parallel to the greater trochanter of the femur. 5. A straight leg cane is used if the client only needs minimal support for an affected leg. - 3, 4, 5 (Rationale: The cane should create no more than 30 degrees of flexion of the elbow, and the top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist. A straight leg cane is sometimes used if the client needs only minimal support for an affected leg. A hemi-cane or quad-cane provides a broader, not narrower, base for the cane and therefore more support. The cane is placed on the unaffected side and not the affected side.) The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be *most* concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites - 3 (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.) 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? 1. Left hand, and 6 inches lateral to the left foot 2. Right hand, and 6 inches lateral to the right foot 3. Left hand, placing the cane in front of the left foot 4. Right hand, placing the cane in front of the right foot - 1 (Rationale: The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.) 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? 1. Canes prevent falls, not cause them. 2. The physical therapist will determine if the cane is inadequate. 3. The cane would help break a fall, even if the client does slip. 4. The cane has a flared tip with concentric rings to provide stability. - 4 (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 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? 1. A bone fragment has injured the nerve supply in the area. 2. An injured artery causes impaired arterial perfusion through the compartment. 3. Bleeding and swelling cause increased pressure in an area that cannot expand. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles. - 3 (Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment triggering the signs/symptoms.) 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. 1. Relatives at the bedside 2. Stress from the fracture 3. Eyeglasses left at home 4. Unfamiliar hospital setting 5. Side effects of medications 6. Hearing aid available and in working order - 2,6,4,5 (Rationale: Confusion in the older client with hip fracture could result from the eyeglasses being left at home, an unfamiliar hospital setting, stress from the fracture, side effects of medications, concurrent systemic diseases, or cerebral ischemia. Relatives at the bedside would help the client's functional level, and hearing aids enhance the client's interaction with the environment and can reduce disorientation.) 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? 1. Trochanter roll to prevent abduction while turning 2. Pillow to keep the right leg abducted during turning 3. Pillow to keep the right leg adducted during turning 4. Trochanter roll to prevent external rotation while turning - 2 (Rationale: Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client.) 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.* 1. Ensure that the machine is well padded. 2. Assess the client's response to the machine. 3. When the machine is not in use, store it on the floor. 4. Check the cycle and range-of-motion settings once a day. 5. Turn off the machine while the client is having a meal in bed. 6. Make sure that the joint being moved is properly positioned on the machine. - 1,2,5,6 (Rationale: While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach.) 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? 1. Obtain a walker to minimize weight bearing by the client on the affected leg. 2. Apply an Ace wrap around the dressing, and put ice on the knee while sitting. 3. Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.