MUSCULOSKELETAL ASSESSMENT 1

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THIS ASSESSMENT IS POWERED BY ACHIEVERS NCLEX-RN CONSULT. visit us at www.achieversnclexrn.com

ASSESSMENT AREAS: STRAIN, SPRAIN, FRACTURES, TRACTION, TOTAL KNEE REPLACEMENT

PASSMARK: 18/30

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Q1. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:
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1 point

A. Fracture

B. Strain

C. Sprain

D. Contusion

Q2. A client diagnosed with a severe sprain of the right ankle must avoid all weight-bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? (Select all that apply.)
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1 point

1.Elbows are flexed 20 to 30 degrees.

2.Touches down with the right foot.

3.Ensures rubber tips are on both crutches.

4.Bears weight on the armpits.

5.Keeps crutches 14 to 16 inches out to side.

Required

Q3. The nurse has just finished assisting the physician in applying a fiberglass cast to a client with a severe ankle sprain. The client inquires about the length of time to wait to walk on the cast. How much time will the nurse instruct the client to wait until walking again?
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1 point

A. 8 hours

B. Half an hour

C. After 24 hours

D. After 48 hours

A4. A nurse is educating a client with a sprained ankle on how to care for it at home. Which interventions should be included in the education?

Select all that apply.

1 point

A. Warm compresses

B. Resting that leg

C. Elevation on 2 pillows

D. Ice packs

E. Compression with Ace wrap

Required

Q5. The school nurse accompanies a group of school-age clients on a field trip. While exiting the bus, one of the clients falls and sustains a leg injury. The nurse suspects the client's leg is fractured. Which action does the nurse implement first?
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1 point

1. Contact the client's parent.

2. Help the client get back on the bus.

3. Transport the client to a nearby hospital.

4. Bandage the client's legs together.

Q6. The nurse is caring for a client who experienced an ankle sprain while skiing. Which teaching will the nurse include? Select all that apply.

1 point

1. Do not ski again until the ankle is fully healed

2. Elevate the affected leg when sitting or lying down

3. Get plenty of rest in the coming days to facilitate healing

4. Apply ice to the ankle no longer than 20 minutes at a time

5. Wrap the ankle with an elastic bandage to provide it with support

Q7. An adolescent client with a fractured tibia asks the nurse what can be done to relieve itching under the cast. Which response by the nurse is accurate?
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1 point

1. Apply cool air under the cast with a blow-dryer.

2. Use sterile applicators to scratch the itch.

3. Insert crushed ice under the cast.

4. Apply hydrocortisone cream under the cast using sterile applicator.

Q8. A client falls while shopping and sustains a wrist fracture. The nurse notes a large amount of wrist swelling, deformity, and minor skin avulsion. Which is the nurse’s priority action in the provision of care for this client?
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1 point

Option A

Option B

Option C

Option D

Q9. The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time?
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1 point

1. Administer prescribed IV morphine

2. Facilitate hourly client use of incentive spirometry

3. Instruct client on gently splinting injury during coughing

4. Notify the health care provider immediately

Q10. A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?
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1 point

1. Document a description of the injury

2. Question the mother about where the infant sleeps

3. Report the injury per facility protocol

4. Separate the mother from the infant

Q11. The nurse provides care to a client diagnosed with a pelvic fracture after a motor vehicle accident. The nurse notes that the client is agitated and attempting to get out of bed. The client has removed the IV and reports shortness of breath. The client's blood pressure is 90/58 mm Hg, respirations 28 breaths/minute, pulse 133 beats/minute, and O2 sat 78% on 3.5 L/minute of oxygen. Which action will the nurse perform?

(Select all that apply.)

1 point

1. Administer normal saline 500 mL bolus.

2. Assess breath sounds.

3. Obtain arterial blood gases (ABG).

4. Begin cardiopulmonary resuscitation (CPR).

5. Continue to administer oxygen at 3.5 L/m via nasal cannula.

6. Establish vascular access.

Required

Q12. A nurse is helping a client who is in bed to move up toward the head of the bed. The client uses an overhead bar to help with moving up in the bed. Which best explains how this bar will help prevent risk to the client?

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1 point

1. It reduces skin friction

2. It promotes circulation

3. It provides range of motion

4. It reduces the risk of fracture

Q13. The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches?

Select all that apply.

1 point

1. Keep a clear path to the bathroom

2. Look down at the feet when walking

3. Remove scatter rugs from floors

4. Use a small backpack/shoulder bag to hold personal items

5. Wear rubber-soled shoes, preferably without laces

Required

Q14. The purpose of a splint is to
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1 point

A. Manage complex or unstable fractures.

B. Provide permanent support for a fracture.

C. Immobilize and allow for tissue swelling.

D. Wrap around an injury for full protection.

Q15. A nurse is caring for a client who has a simple fracture of the humerus. Which of the following images represents a simple fracture?

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1 point

A. A

B. B

C. C

D. D

Q16. A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity.
The most appropriate crutch-walking gait the nurse should teach the client is the
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1 point

A. Two-point gait

B. Three-point gait

C. Four-point gait

D. Swing-through gait

Q17. An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first?
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1 point

1. Decrease rate of IV fluids.

2. Neurovascular checks of affected leg.

3. Elevate the head of the bed.

4. Call the active response team.

Q18. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
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1 point

A. Swelling of the left thigh

B. Increased skin temperature of the foot

C. Prolonged reperfusion of the toes after blanching

D. Increased blood pressure

Q19. An adolescent is diagnosed with a closed head injury following a motor vehicle accident. The nurse notes clear drainage from the left nostril and is aware the priority action is what?
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1 point

1. Contact the healthcare provider.

2. Carefully suction both nostrils.

3. Ask client to gently blow nose.

4. Test the drainage for glucose.

Q20. Which of the following would a nurse expect on assessment of a client with fat embolism syndrome after femur fracture? (Select all that apply.)
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1 point

A. Pain with movement of the affected extremity

B. Restlessness and confusion

C. Fever

D. Petechial rash on the neck, chest, and axilla

Required

Q21. A client is being discharged with halo traction. What should the nurse teach about home care of this traction?

Select all that apply
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1 point

1. Showering is permitted.

2. Apply baby powder under the halo vest to prevent irritation.

3. Never pull on any part of the halo traction.

4. Clean around pins at least twice a day using sterile technique.

5. Driving is allowed after discharge.

Required

Q22. A nurse is planning care for a child who is in skeletal traction. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

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1 point

A. Remove the weights to reposition the client.

B. Provide a high-fiber diet.

C. Assess the pin sites every 4 hr.

D. Limit oral fluid intake.

E. Ensure the rope's knot is in contact with the pulley.

Required

Q23. While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient’s injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing?
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1 point

A. Keeping the pulley system tightened so that they may not move freely

B. Check the ropes for fraying or breaks

C. Keep the weights above the floor

D. Ensure proper body alignment

Q24. The nurse provides care for a client who just returned from surgery after a right total knee replacement. It is important for the nurse to take which action?
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1 point

1. Change the surgical dressing if it becomes saturated or loose.

2. Assist the client to ambulate in the room and in the hall.

3. Encourage use of the incentive spirometer three times per day.

4. Apply sequential compression devices to the lower extremities.

Q25. An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse’s suspicion?
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1 point

A. Blood pressure of 90/55 mmHg; weak, thready pulse; slightly elevated temperature.

B. Cool, clammy skin; bounding pulse; cough.

C. Headache, Lethargy, and abdominal pain.

D. Fever; warmth, swelling, and redness at the operative site.

Q26. The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor?
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1 point

A. Bleeding on the dressing is 3cm in diameter.

B. The client has a temperature of 100.6°F (38.1°C).

C. The client’s hematocrit is 26%.

D. The urinary output has been 60 during the last 2 hours.

Q27. The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse include in discharge teaching?
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1 point

A. “After this procedure, you will use a wheelchair to get around.”

B. “You will need to resume your anticoagulants.”

C. “Placing a pillow under your knee will help with the pain.”

D. “You may ice the site for one hour at a time.”

Q28. The nurse cares for the patient admitted to the recovery room following a total left hip replacement. The nurse positions the patient in which of the following positions?
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1 point

1. On the right side with the head of the bed slightly elevated and the left hip adducted.

2. On the left side with the head of the bed slightly elevated and the hips flexed 120 degrees.

3. Supine with the knee gatch elevated to 30 degrees and the left hip extended.

4. Supine with the head of the bed slightly elevated and a pillow between the legs.

Q29. The nurse is caring for a client 2 days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
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1 point

A. Stabilize the knee joint during ambulation

B. Promote knee flexion

C. Reduce post-surgical swelling

D. Prevent blood clots

Q30. A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction?
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1 point

1. Faces forward when going up and down the stairs

2. Holds the cane with the right hand

3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs

4. Places full weight on left leg when going down the stairs

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