NCLEX-PN
Musculoskeletal NCLEX Questions with Rationale Questions
Extract:
Question 1 of 5
The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
Question 2 of 5
Which statement made by the family member indicates the need for further teaching?
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
Question 3 of 5
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
Question 4 of 5
The school nurse is completing spinal screenings. Which data require a referral to an HCP?
Correct Answer: D
Rationale: Asymmetrical arm positioning (right lower than left) suggests scoliosis, requiring HCP referral. Symmetrical arms, resolving deformities, and equal spacing are normal.
Question 5 of 5
When the nurse makes rounds at the beginning of the shift, which observation requires the nurse's immediate attention?
Correct Answer: D
Rationale: A pillow under the head in cervical traction can alter the alignment and reduce traction effectiveness, requiring immediate removal. The other observations indicate proper setup.