NCLEX-PN
NCLEX Questions for Musculoskeletal Disorders Questions
Extract:
Question 1 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.
Question 2 of 5
If the client is allergic to penicillin, the nurse must question a medical order for which type of antibiotic?
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
Postoperatively, the client screams obscenities at the nurse after realizing that the injured forearm is missing. Which nursing action is most appropriate at this time?
Correct Answer: B
Rationale: Staying quietly with the client provides emotional support during a grief reaction to amputation, promoting trust. Leaving, reprimanding, or medicating without engagement dismisses the client's feelings.
Question 4 of 5
Which signs/symptoms indicate to the nurse the client has developed osteoporosis?
Correct Answer: A
Rationale: Height loss indicates vertebral compression fractures, a common osteoporosis sign. Weight loss, hand pain, and uric acid elevation are unrelated.
Question 5 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?
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.