NCLEX-PN
NCLEX Questions for Musculoskeletal Disorders Questions
Extract:
Question 1 of 5
The client with DM is admitted with possible osteomyelitis secondary to an ankle wound. The client's ankle is painful, red, swollen, and warm, and the wound is persistently draining. The client's temperature is 102.2°F (39°C). Based on the client's status, which HCP order should the nurse plan to defer until later?
Correct Answer: D
Rationale: D. The nurse should defer teaching. Pain and an elevated temperature are barriers to learning.
Question 2 of 5
The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation?
Correct Answer: C
Rationale: C. Weights should be hanging freely, but weights should never be removed (unless a life-threatening situation occurs) because removal could result in injury and defeats the purpose of the traction. The lengths of the ropes need to be adjusted so the weights do not rest on the bed frame.
Question 3 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.
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 4 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.
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 5 of 5
The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.