NCLEX-PN
Musculoskeletal Questions NCLEX Questions
Extract:
Question 1 of 5
The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following?
Correct Answer: B
Rationale: A semi-reclining position post-myelogram prevents spinal headache by reducing cerebrospinal fluid leakage.
Question 2 of 5
The client has been flat in bed in traction for two weeks, and she is to be allowed out of bed for the first time today. What must the nurse be particularly alert for when getting the client out of bed?
Correct Answer: C
Rationale: Prolonged bed rest increases the risk of orthostatic hypotension when first mobilizing, requiring careful monitoring.
Question 3 of 5
After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?
Correct Answer: A
Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.
Question 4 of 5
The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply.
Correct Answer: D,E
Rationale: D. Assessment of pulses and sensation is important because compression of nerves and blood vessels can occur with shoulder dislocation. A shortened arm on the right indicates that the right shoulder is affected. E. The client is in severe pain and requires pain control.
Question 5 of 5
The nurse starting the shift is determining priorities for the day. Prioritize the order that the nurse should plan to assess the four clients.
Correct Answer: B,A,D,C
Rationale: B. The client who has a right lower leg cast whose right foot is cold to the touch should be assessed first. The data could indicate compartment syndrome, which is an emergent condition. A. The client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale should be assessed second because pain is a priority in a postoperative client and should be addressed in a timely manner, but this is not an emergent situation. D. The client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago should be assessed third for the presence of urinary retention. Usually the client should void within 6 hours after a urinary catheter has been removed. C. The client who had a THR and 200-mL wound drain output during the past 8 hours should be assessed last. This amount of output is a common finding following a THR due to the vascular nature of the operative site.