NCLEX Questions for Musculoskeletal Disorders

Question 1 of 5

The nurse assesses the client 4 hours following a left TKR. The client has a knee immobilizer in place with medial and lateral packs that are warm. An autotransfusion wound drainage system has 350 mL collected. The client has not voided since before surgery but does not express a need. Which interventions should the nurse plan to implement at this time? Select all that apply.

A. Reinfuse the salvaged blood from the wound drainage system.B. Remove the immobilizer to place the knee in 90-degree flexion.C. Stand the client at the bedside to facilitate bladder emptying.D. Place the left leg in a continuous passive motion device (CPM).E. Replace the warm packs in the knee immobilizer with ice packs.

Correct Answer: A,E

Rationale: A. An autotransfusion drainage system is used in the immediate postoperative period if extensive bleeding is anticipated. Collected drainage can be reinfused up to 6 hours postoperative. E. Ice packs, used to reduce swelling and control bleeding, are replaced every 2 hours. If they have warmed, they need to be replaced.

Question 2 of 5

If the client is allergic to penicillin, the nurse must question a medical order for which type of antibiotic?

A. An aminoglycoside such as gentamicin sulfate (Garamycin)B. A cephalosporin such as cefaclor (Ceclor)C. A tetracycline such as doxycycline (Vibramycin)D. A sulfonamide such as trimethoprim/sulfamethoxazole (Bactrim)

Correct Answer: B

Rationale: Cephalosporins (e.g., cefaclor) have a cross-sensitivity with penicillin, risking allergic reactions in penicillin-allergic clients. The other antibiotics listed do not share this cross-reactivity.

Question 3 of 5

The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?

A. Resistance with specific leg movementB. Knee or hip flexion with head flexionC. A high-pitched cry with neck flexionD. Hyperextension of the head and neck

Correct Answer: D

Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.

Question 4 of 5

The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply.

A. Place pillows or a wedge pillow between the client's legs to keep them abducted.B. Have the client flex the unaffected hip and use the trapeze to help move up in bed.C. Raise the head of the bed to no more than 90 degrees when the bed is placed contour.D. Place a pillow between the client's knees when initially assisting the client out of bed.E. Applies antiembolism stockings that should not be removed for 24 hours postoperatively.

Correct Answer: A,B,D

Rationale: A. A pillow should be used to maintain abduction to prevent dislocation. B. Using the trapeze and flexing the unaffected legs while keeping the affected leg straight help prevent flexion with position changes. The client's hip should not be flexed more than 90 degrees. D. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation.

Question 5 of 5

The HCP is adducting the newborn's hip while pushing the thigh forward to detect developmental dysplasia of the hip (DDH). The nurse should identify this screening test as which maneuver?

A. Barlow maneuverB. Pavlik maneuverC. Gowers maneuverD. Allis maneuver

Correct Answer: A

Rationale: The Barlow maneuver involves adducting the hip and pushing the thigh to detect DDH by assessing for hip dislocation.

NCLEX Questions for Musculoskeletal Disorders | Nurselytic

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