NCLEX RN Questions: Musculoskeletal Injuries (61-65)

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61. A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites?

a) loose pin sites
b) clear drainage from the pin sites
c) purulent drainage from the pin sites
d) redness and swelling around the pin sites

62. A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete neurovascular assessment of the affected extremity and plans to assess:

a) vital signs and bilateral lung sounds
b) warmth of the skin and the temperature in the affected extremity
c) pain level and for the presence of edema in the affected extremity
d) color, sensation, movement, capillary refill, and pulse of the affected extremity

63. A client in the emergency department has a cast applied. The client arrives at the nursing unit, and the nurse prepares to transfer the client into the bed by:

a) placing ice on top of the cast
b) supporting the cast with the fingertips only
c) asking the client to support the cast during transfer
d) using the palms of the hands and soft pillows to support the cast

64. A nurse is caring for a client who has been placed in Buck's extension traction. The nurse provides for countertraction to reduce shear and friction by:

a) using a footboard
b) providing an overhead trapeze
c) slightly elevating the foot of the bed
d) slightly elevating the head of the bed

65. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that:

a) A bone fragment has injured the nerve supply in the area
b) an injured artery causes impaired arterial perfusion through the compartment
c) bleeding and swelling cause increased pressure in an area that cannot expand
d) the fascia expands with injury, causing pressure on underlying nerves and muscles






NCLEX RN Questions
Answers and Rationale

61) B

- A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified.

62) D

- A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

63) D

- The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

64) C

- 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. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client.

65) C

- Compartment syndrome is caused by bleeding and swelling within a compartment, which is 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 symptoms.



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NCLEX RN Questions about Musculoskeletal Injuries (1-8)


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NCLEX RN Questions about Musculoskeletal Injuries (66-70)


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NCLEX RN Questions about Musculoskeletal Injuries (56-60)

Welcome to NCLEX RN Questions about Musculoskeletal Injuries. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


56. A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications?

a) trim the rough edges of the cast after it is dry
b) weigh-bearing on the right leg is allowed once the cast feels dry
c) expect burning and tingling sensations under the cast for 3 to 4 days
d) keep the right ankle elevated above the heart level with pillows for 24 hours

57. An older adult female client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign or symptom that indicates a complication associated with crutch walking?

a) left leg discomfort
b) weak biceps brachii
c) triceps muscle spasms
d) forearm muscle weakness

58. A nurse is caring for a client with Buck's traction and is monitoring the client for complications of the traction. Which assessment finding indicates a complication?

a) weak pedal pulses
b) drainage at the pin sites
c) complaints of discomfort
d) warm toes with brisk capillary refill

59. A client has fallen and sustained a leg injury. Which question would the nurse ask the cleint to help determine if the injury caused a fracture?

a) is the pain a dull ache?
b) is the pain sharp and continuous?
c) does the discomfort feel like a cramp?
d) does the pain feel like the muscle was stretched?

60. The nurse is assessing the casted extremity of a client for signs of infection. Which of the following findings is indicative of infection?

a) dependent edema
b) diminished distal pulse
c) coolness and pallor of the skin
d) presence of a "hot spot" on the cast





NCLEX RN Questions:
Answers and Rationale

56) D

- Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately. Option 1 is incorrect. The client and/or family may be taught how to "petal" the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity.

57) D

- Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking.

58) A

- Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction.

59) B

- Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness.

60) D

- Signs and symptoms of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of "hot spots," which are areas on the cast that are warmer than others. The physician should be notified if any of these occur.


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NCLEX RN Questions about Musculoskeletal Injuries (1-8)


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NCLEX RN Questions about Musculoskeletal Injuries (61-65)

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NCLEX RN Questions about Delegation and Prioritization Questions 101-105

 Welcome to NCLEX RN Questions about Delegation and Prioritization. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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101. A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the LPN?

a) a client who needs assistance with grooming
b) a client who needs frequent ambulation
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs assistance with hygiene measures


102. A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant?

a) assisting a profoundly developmentally disabled child to eat lunch
b) obtaining frequent oral temperatures on a client
c) accompanying a 51-year old man, being discharged to home following a bowel resection
d) collecting a urine specimen from a 70-year old woman admitted 3 days ago

103. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

a) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
b) a postoperative client preparing fro discharge
c) a client scheduled for a chest x-ray
d) a client requiring daily dressing changes

104. A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant?

a) a client requiring twice -daily dry dressing changes
b) a client requiring frequent ambulation with a walker
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

105. A client with a spinal cord injury develops a severe, pounding headache. The client is diaphoretic, hypertensive, and bradycardic and complains of nausea and nasal congestion. The nurse determines that the client is experiencing autonomic hyperreflexia (autonomic dysreflexia). Which action would the nurse take first?

a) notify the physician
b) document the findings
c) perform a rectal examination
d) place the client in a sitting position






NCLEX RN:
Answers and Rationale

101) C

- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Option C can be assigned to the LPN because this staff member can perform certain invasive procedures. Noninvasive interventions can be assigned to a nursing assistant. These include the tasks identified in options A, B, and D.

102) A

- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore a higher potential for complications such as choking and aspiration. The remaining three options include no data indicating that these tasks carry any unforeseen risk.

103) A

- Airway is always a high priority, so the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options B, C, and D would be an intermediate priority.

104) B

- Assignment of tasks needs to be implemented on the basis of the job description of the nursing assistant, the level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. Although a nursing assistant may be trained to administer an enema (depending on state practice acts and agency policy), a rectal suppository needs to be administered by a licensed nurse. Option B is the most appropriate assignment for the nursing assistant.

105) D

- Autonomic hyperreflexia is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction), or stimulation of the skin. When autonomic hyperreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse would then perform a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately via a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or broken skin. The physician is notified, and the nurse documents the occurrence and the actions taken.


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NCLEX Review about Ear Infection 46-50

Welcome to NCLEX Review about Ear Infection. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination:

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46. A nurse is caring for a hospitalized client with an acute attack of Meniere's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which of the following responses would the nurse make to the client regarding the hearing loss?

a) it will take several weeks before the hearing returns
b) the hearing loss will fluctuate for a period of 1 week
c) the attack leaves a hearing loss in the involved ear
d) the hearing will return to normal

47. A nurse is reviewing the physician's orders on a client admitted to the hospital with a diagnosis of an acute attack of Meniere's disease. Which of the following orders, if noted on the client's chart, would the nurse question?

a) the administration of a sedative
b) the administration of an antihistamine
c) the administration of vasoconstrictor
d) bedrest

48. A nurse is providing discharge instructions to the client who was hospitalized for an acute attack of Meniere's disease. Which of the following statements, if made by the client, indicates a need for further instructions?

a) I need to take the diuretics to decrease the fluid in the ear
b) I need to take antihistamine as prescribed
c) I need to take a vasodilator
d) it is not necessary to restrict salt in my diet

49. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse prepares instructions for the client regarding home care after the procedure. Which statement by the client indicates a need for further instructions?

a) I need water out of the ear canal for at least 3 weeks
b) I need to avoid air travel for at least 1 year
c) I need to notify the physician if I experience any persistent dizziness
d) I need to avoid bending and lifting heavy objects for at least 3 weeks

50. A community health nurse is conducting a health-screening clinic and is scheduled to perform hearing tests on the clients who attend the screening session. Several nurses have volunteered to assist with the screening clinic. The community health nurse instructs the nurses to perform a voice test to assess hearing in the clients and tells the nurses to do which of the following?

a) with back to the client, whisper a statement, and determine if the client can clearly repeat it
b) face the client, and whisper a statement while the client blocks both ears
c) stand 4 feet away from the client when talking to the client, and determine if the client can hear at this distance
d) quietly whisper a statement, and ask the client to repeat it to determine the hearing ability





NCLEX Review
Answers and Rationale

46) C
- After the acute phase, remission occurs, but symptoms of the disease will recur with two or three acute attacks occurring per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss, varying from slight to complete. It takes several weeks before all symptoms subside after an attack, leaving a loss of hearing in the involved ear. Options A, B, and D are incorrect.

47) C

- Medical interventions during the acute phase of Meniere's disease include using atropine or diazepam (Valium) to decrease the autonomic nervous system function. Diphenhydramine (Benadryl) may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack, and when allowed to be out of bed, the client will need assistance with walking, sitting, or standing.

48) D
- Management during remission includes the use of diuretics to decrease the fluid and thereby decrease pressure in the endolymph. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet is prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client's hearing, and careful medical management helps achieve this in most clients with Ménière's disease.

49) B

- After stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client also is instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If sudden hearing loss, fever, or severe persistent vertigo or dizziness develops, the physician should be notified.

50) D

- The examiner should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Options A, B, and C are incorrect.


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NCLEX Review about Ear Infection 1-5

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