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Flashcards in Musculoskeletal Deck (150)
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61

The nurse is preparing the preoperative client for a total hip replacement (THR).
Which information should the nurse include concerning postoperative care?
1. Keep abduction pillow in place between legs at all times.
2. Cough and deep breathe at least every four (4) to five (5) hours.
3. Turn to both sides every two (2) hours to prevent pressure ulcers.
4. Sit in a high-seated chair for a flexion of less than 90 degrees.

4. Using a high-seated toilet and chair will
help prevent dislocation by limiting the
flexion to less than 90 degrees.

62

The client that is one (1) day postoperative total hip replacement complains of hearing
a “popping sound” when turning. What assessment data should the nurse report
immediately to the surgeon?
1. Dark red–purple discoloration.
2. Equal length of lower extremities.
3. Groin pain in the affected leg.
4. Edema at the incision site.

3. Groin pain or increasing discomfort in the
affected leg and the “popping sound” indicate
that the leg has dislocated and should
be reported immediately to the HCP for a
possible closed reduction.

63

The nurse is preparing the client who received a total hip replacement for discharge.
Which statement would indicate that further teaching is needed?
1. “I should not cross my legs because my hip may come out of the socket.”
2. “I will call my HCP if I have a sudden increase in pain.”
3. “I will sit on a chair with arms and a firm seat.”
4. “After three (3) weeks, I don’t have to worry about infection.”

4. Infections are possible months after surgery.
Clients should monitor temperatures
and report any signs of infection.

64

When assessing the wound of a client who had a total hip replacement, the nurse finds
small, fluid-filled lesions on the right side of the dressing. What explanation is the most
probable rationale for this occurrence?
1. These were caused by the cautery unit in the operating room.
2. These are papular wheals from herpes zoster.
3. These are blisters from the tape used to anchor the dressing.
4. These macular lesions are from a latex allergy.

3. Fluid-filled blisters are from a reaction to
the tape and usually occur along the edge
of the tape.

65

Which topics should the nurse include in the discharge teaching plan for a client after
having a total hip replacement? Select all that apply.
1. Weight-bearing limits.
2. Use of assistive devices.
3. Gradual increase in activity.
4. Medication therapy.
5. Periods of rest.

1. Clients need to understand the amount of
weight bearing to prevent injury.
2. Teaching the safe use of assistive devices is
necessary prior to discharge.
3. Increases in activity should occur slowly to
prevent complications.
4. Using medication therapy, including analgesics,
anti-inflammatory agents, or muscle
relaxants, should be taught so that client is
comfortable while ambulating.
5. The client should be encouraged to rest
periodically to promote healing and increase
energy.

66

The nurse is preparing a plan of care for the client who has had a total hip replacement.
Which outcome would be most appropriate for this client?
1. The client has limited amount of pain relief.
2. The client will have limited ability to ambulate.
3. The client will have hip instability for several months.
4. The client will have adequate hip joint motion.

4. The hip should have functional motion.

67

When assessing the client six (6) hours after having a right total knee replacement,
which data should the nurse report to the surgeon?
1. A total of 100 mL of red drainage in the autotransfusion drainage system.
2. Pain relief after using the patient-controlled analgesia (PCA) pump.
3. Cool toes, distal pulses palpable, and pale nail beds bilaterally.
4. Urinary output of 60 mL of clear yellow urine in three (3) hours.

4. The urinary output is not adequate; therefore
the surgeon needs to be notified. This
is only 20 mL per hour. The minimum
should be 30 mL per hour.

68

When preparing the client for the transition to home rehabilitation after having a total
knee replacement, which information regarding discharge teaching would the nurse
include?
1. Deep breathe and cough every two (2) hours.
2. Procedure for emptying Jackson-Pratt drainage.
3. Burning or frequency of urination is expected.
4. Modify the home for altered mobility.

4. Modification of the home is essential to the
rehabilitation of the client using assistive
devices for ambulation. The postoperative
goals for this client are to maximize mobility
and promote health.

69

When developing the plan of care for the client having a total knee repair, which of the
expected outcomes would the nurse include? Select all that apply.
1. The client has effective pain management.
2. The client does not smoke or use tobacco products.
3. The client ambulates within the weight-bearing limits.
4. The client participates in activities of daily living.
5. The client is able to return to his or her previous lifestyle.

1. The client needs to have the pain managed
so that the client can be as active as possible.
This will help avoid complications of
immobility.
2. Clients should not be able to smoke after
surgery because smoking increases the risk
for pulmonary complications. Most hospitals
do provide smoking areas outside the
building.
3. The client must ambulate within the
weight-bearing restrictions so that the knee
will not be injured, which may delay healing.
4. All clients should be encouraged to do as
much self-care as possible to assist with
self-esteem.
5. Not all clients will able to return to their
previous life roles and activities but it is the
goal. They should be assisted with coping
skills so that they will be able to adapt to
any changes.

70

The nurse is caring for the client who had a total knee replacement (TKR). Which data
would the nurse observe to determine if the nursing interventions are effective?
1. The client’s lungs have bilateral crackles.
2. The client’s knee has flexion of 45 degrees.
3. The client participates in self-care activities.
4. The client has reduced pain using a single approach.

3. Clients should participate in care, in decision-
making, and in activities that promote
mobility and adaptation to the life changes
postoperatively

71

The nurse is assessing the client who is immediately postoperative from a total knee
replacement. Which assessment data would warrant immediate intervention?
1. T 99F, HR 80, RR 20, and BP 128/76.
2. Pain in the unaffected leg during dorsiflexion of the ankle.
3. Bowel sounds heard intermittently in four quadrants.
4. Diffuse, crampy abdominal pain.

2. Pain with dorsiflexion of the ankle indicates
deep vein thrombosis. This can be from immobility
or surgery; therefore pain should
be assessed on both legs.

72

The nurse is working on an orthopedic floor. Which client should the nurse assess first
after the change of shift report?
1. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
2. The 64-year-old female who had a left total knee replacement with confusion.
3. The 88-year-old male who had a right total hip replacement with an abduction
pillow.
4. The 50-year-old postoperative client who has a continuous passive motion (CPM)
device.

2. This is an abnormal occurrence from this
information. This client should be seen first
because confusion is a symptom of hypoxia.

73

The 50-year-old client came to the health-care provider’s office for an annual physical
examination. Which information should the nurse assess to rule out osteoporosis? Select
all that apply.
1. Family history of osteoporosis.
2. Estrogen or androgen deficit.
3. Use of tobacco products.
4. Level and amount of exercise.
5. Alcohol intake.

1. Clients are more prone to have osteoporosis
if there is a genetic predisposition.
2. Clients who are deficient in either estrogen
or androgen are at risk for osteoporosis.
3. Clients who smoke are more at risk for
osteoporosis.
4. Regular, weight-bearing exercise promotes
healthy bones.
5. Clients who consume alcohol and have
diets low in calcium are at a higher risk for
osteoporosis.

74

In preparing a plan of care for a client diagnosed with carpal tunnel syndrome, which
intervention should the nurse include?
1. Teach hyperextension exercises to increase flexibility.
2. Monitor safety during occupational hazards.
3. Prepare for the insertions of pins or screws.
4. Monitor dressing and drain after the fasciotomy.

2. The nurse should monitor for potential
injuries resulting from the alterations in
motor, sensory, and autonomic function of
the first three digits of the hand and palmar
surface of the fourth. These alterations can
interfere with pinching or grasping, which,
in turn, increases the risk for injury in
clients whose occupations require the use
of equipment such as jackhammers and
computers.

75

When the manager is completing the client assignments for the next shift, which nurse
should the manager assign to the client recovering from a repair of the hallux valgus?
1. A new graduate nurse.
2. An experienced nurse.
3. A nurse practitioner.
4. An unlicensed nursing assistant.

1. A new graduate is the best choice for this
client. The client’s surgery is not a highrisk
procedure but would require assessment
and pain management.

76

The client has been scheduled for a computed tomography (CT) scan. Which information
is most important for the nurse to obtain before the procedure?
1. The assessment of the client’s pain.
2. Vital signs are within normal limits.
3. Whether client has allergies to seafood.
4. Type of intravenous fluid being administered.

3. This is the most important information the
nurse should obtain. Any client who is
allergic to seafood cannot be injected with
the iodine-based contrast. This contrast
would cause an allergic response that could
endanger the client’s life.

77

The student nurse asks the emergency department nurse why the nurse is careful to
maintain asepsis when caring for the client with an open fracture of the right humerus.
Which rationale explains the nurse’s actions?
1. It is a policy to prevent the transmission of blood borne pathogens.
2. Clients who have open fractures are at a high risk for osteomyelitis.
3. Failure to maintain asepsis may result in a malpractice lawsuit.
4. The client has compromised immunity based on the laboratory values.

2. The open skin and exposure of the bone is
a direct pathway for infection and osteomyelitis.

78

While working in the day surgery department, the nurse is caring for the client two (2)
hours after having a right knee arthroscopy. Which intervention should the nurse implement?
1. Encourage the client to perform range-of-motion exercises.
2. Monitor the amount and color of the urinary output hourly.
3. Check the client’s pulses distally and assess the toes.
4. Monitor the client’s vital signs every eight (8) hours.

3. Pulses and circulation checks should be
done every one (1) to two (2) hours postoperatively.

79

The nurse is responsible for teaching the client to take Fosamax, a bisphosphonate.
Which information should the nurse include?
1. Take this medication with a full glass of water.
2. Take with breakfast to prevent gastrointestinal upset.
3. Use sunscreen to prevent sensitivity to sunlight.
4. This medication increases calcium reabsorption.

1. The client needs to take this medication
with a full glass of water and remain upright
for at least 30 minutes to reduce the risk of
esophagitis.

80

The school nurse is completing spinal screenings. Which data would require a referral
to an HCP?
1. Bilateral arm lengthens while bending over at the waist.
2. A deformity that resolves when the head is raised.
3. Equal spacing of the arms and body at the waist.
4. A right arm lower than the left while bending over at the waist.

4. Unequal arm length may indicate scoliosis,
and further assessment is needed by an
HCP.

81

The nurse is working in the clinic and assesses the client with complaints of pain and
numbness in the left hand and fingers. What data should the nurse look for when
assessing this client to determine the cause of the complaints?
1. Symmetric movements of elbows and shoulders.
2. A capillary refill time of less than three (3) seconds.
3. A history of any repetitive movements during work or leisure.
4. Bilateral anterior and posterior deep-tendon reflexes.

3. This information would assist with the diagnosis of carpal tunnel syndrome. Clients with this disorder experience pain and numbness.

82

The nurse is teaching the client diagnosed with osteoporosis about the medication
calcitonin, a thyroid hormone. Which data would indicate that the teaching has been
effective?
1. The client states, “I should change nostrils from day to day.”
2. The client states, “I need to drink a lot of water when I take my medicine.”
3. The client demonstrates how to dilute the medication with vitamin D.
4. The client states, “This will help the calcium leave my bones.”

1. This should be taught so that when the client takes the medication intranasally it will decrease irritation from administration.

83

The client asks the nurse, “Why am I having this bone scan?” Which statement would
be the nurse’s best response?
1. “You seem anxious. Tell me about your anxieties.”
2. “Why are you concerned? Your HCP ordered it.”
3. “I’ll have the radiologist come back to explain it again.”
4. “A bone scan looks for cancer or infection inside the bones.”

4. This statement simply answers the client’s
question.

84

The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention
should the nurse delegate to the unlicensed nursing assistant?
1. Prepare the client by removing all metal objects.
2. Inject the contrast into the intravenous site.
3. Administer a sedative to the client to decrease anxiety.
4. Explain why the client cannot have any breakfast.

1. Metal objects such as jewelry and zippers
can interfere with the magnetic imaging
and pose a danger to the client as a result of
the magnetic properties of the equipment.
Clients with pacemakers should not have
an MRI because the magnet will disrupt the
unit’s program. This intervention can be
delegated to the unlicensed nursing assistant.

85

A client is admitted to the orthopedic floor after having sustained a fractured femur in
a motor-vehicle accident. Which data would require immediate intervention by the
nurse? Select all that apply.
1. The client becomes restless and irritable.
2. The client has tachypnea and tachycardia.
3. The client has petechiae over the neck and chest.
4. The client has a high arterial oxygen level.
5. The client has yellow globules floating in the urine.

1. The first sign of a fat embolism syndrome is
an altered mental status. This requires an
immediate response to save this client’s life.
The health-care provider should be notified.
2. The client will experience rapid heart rate
and rapid respiratory rates as a compensatory
response to hypoxia. The nurse should
recognize this situation and intervene. The
health-care provider should be notified.
3. Petechiae are macular, red–purple pinpoint
bleeding under the skin. The appearance of
petechiae is a classic sign of fat embolism
syndrome.
5. Yellow globules in the urine are fat globules
released from the bone as it breaks.
This should be reported immediately.

86

The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP
order would the nurse question?
1. Administer intravenous heparin.
2. Administer intravenous fluids.
3. Keep the O2 saturation higher than 93%.
4. Administer a loop diuretic.

4. The nurse should question this order. This
will decrease the client’s hydration and may
result in further embolism.

87

The client has been admitted to the hospital for repair of a fractured femoral neck.
Which would be the expected short-term goal for this client?
1. The client will be turned every two (2) hours to prevent skin breakdown.
2. The client will have a decrease in muscle spasms and pain in the affected leg.
3. The client will have no objective or subjective signs or symptoms of infection.
4. The client will be able to ambulate down the hallway to the nurse’s station.

2. This is an expected outcome for a preoperative
client with a fractured femoral neck.
This injury causes painful muscle spasms.
Buck’s traction is applied to decrease or
prevent spasms by maintaining the position
and alignment of the bone fragments.

88

The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight
heparin. Which intervention should the nurse implement?
1. Monitor the client’s serum aPTT.
2. Encourage oral and intravenous fluids.
3. Give with food to protect the stomach.
4. Administer in the “love handles.”

4. Administering this medication in the prescribed
areas would ensure safety and decrease
the risk of abdominal trauma.

89

When caring for the client with a fractured right hip who has Buck’s traction, which
intervention should the nurse include in the plan of care?
1. Assess the insertion sites for signs and symptoms of infection.
2. Monitor for drainage or odor from under the plaster covering the pins.
3. Monitor the condition of the skin beneath the Velcro™ boot every eight (8) hours.
4. Take weights off for one (1) hour every eight (8) hours and as needed.

3. In Buck’s traction a Velcro boot is used to
attach the ropes to weights to maintain
alignment. Skin covered by the boot can
become irritated and break down. The
nurse should monitor the skin around the
boot for redness and breakdown at least
once every eight (8) hours while maintaining
traction to the leg manually.

90

When caring for a client with a spica cast for a hip injury, what intervention should the
nurse include in the plan of care?
1. Assess client’s popliteal pulses every shift.
2. Elevate the leg on pillows and apply ice packs.
3. Teach the client how to ambulate with a tripod walker.
4. Assess the client for distention and vomiting.

4. The nurse should assess the client for signs
and symptoms of cast syndrome—vomiting
after meals, epigastric pain, and abdominal
distention. This is caused by a partial bowel
obstruction from compression and can lead
to complete obstruction. The client may
still have bowel sounds present with this
syndrome.