Questions 19

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Musculoskeletal RN NCLEX Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse is caring for an older adult 4 days postoperative hip arthroplasty.
Item 1 of 1
Nurses' Notes
0900: Assessment completed, and the client was in bed alert and oriented to person, place, time, and situation. Clear lung fields bilaterally, with an infrequent dry cough. Heart tones S1 and S2. Peripheral pulses palpable and 2+. Skin was warm and dry. Bowel sounds were normoactive and present in all four quadrants. Incision was pink, approximated with staples, with scant serous drainage. Pain rated 4/10 on the Numerical Pain Rating Scale. Client refused to ambulate to the bedside chair for breakfast.

1159: Client informed nurse of their refusal to participate in physical therapy. Once up with PT, the client reported intense pain. The client reports that they have intense 'heaviness' in their left calf and that she needs a 'water pill' because it is swollen. The client was placed back in bed. She reports dyspnea immediately after failed ambulation attempt.

Vital Signs
0900
Blood pressure 139/88 mm Hg
Heart rate 77/min
Respiratory rate 21/min
Temperature 99°F (37.2°C)
Pulse oximetry 92% on room air
1200
Blood pressure 149/91 mm Hg
Heart rate 87/min
Respiratory rate 24/min
Temperature 99°F (37.2°C)
Pulse oximetry 90% on room air

Medical History
• hyperlipidemia
• generalized anxiety disorder
• irritable bowel syndrome
• chronic obstructive pulmonary disease
• diabetes mellitus (type two)
• osteoarthritis


Question 1 of 5

The nurse should recognize that the client may be experiencing

Correct Answer: C, E

Rationale: Venous thromboembolism is suggested by dyspnea, elevated heart and respiratory rates, and calf swelling/tenderness post-hip arthroplasty, indicating possible deep vein thrombosis. Wound infection, hypoxia, and dehiscence are less directly supported.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

Correct Answer:

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Question 5 of 5

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Rationale:

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