Musculoskeletal Questions NCLEX

Musculoskeletal Questions NCLEX Related

Review Musculoskeletal Questions NCLEX related questions and content

The nurse starting the shift is determining priorities for the day. Prioritize the order that the nurse should plan to assess the four clients.

  • A. Client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale
  • B. Client who has a right lower leg cast whose right foot is cold to the touch
  • C. Client who had a THR and 200-mL wound drain output during the past 8 hours
  • D. Client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago
Correct Answer: B,A,D,C

Rationale: B. The client who has a right lower leg cast whose right foot is cold to the touch should be assessed first. The data could indicate compartment syndrome, which is an emergent condition. A. The client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale should be assessed second because pain is a priority in a postoperative client and should be addressed in a timely manner, but this is not an emergent situation. D. The client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago should be assessed third for the presence of urinary retention. Usually the client should void within 6 hours after a urinary catheter has been removed. C. The client who had a THR and 200-mL wound drain output during the past 8 hours should be assessed last. This amount of output is a common finding following a THR due to the vascular nature of the operative site.

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The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?

  • A. Encouraging deep breathing
  • B. Asking him if he understands the full effects of the planned surgery
  • C. Discussing the effects of diabetes on the vascular system
  • D. Having a recovered amputee visit him
Correct Answer: D

Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.

The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?

  • A. Monitor the continuous passive motion machine.
  • B. Apply thigh-high TED hose bilaterally.
  • C. Place the abductor pillow between the legs.
  • D. Encourage the family to perform ADLs for the client.
Correct Answer: A

Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.

After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?

  • A. The client's head becomes severe pain.
  • B. The client's hand becomes reddened.
  • C. The fingers develop muscle spasms.
  • D. The radial pulse feels bounding.
Correct Answer: A

Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.

Which statements made by a parent indicate that appropriate care is being provided for a 4-year-old with spastic-type CP?

  • A. "I perform range of motion (ROM) exercises every 4 hours to help prevent contractures."
  • B. "I give my child a therapeutic massage after the stretching exercises to help manage pain."
  • C. "I minimize the calories I provide with meals because my child is more prone to obesity."
  • D. "I have my child wear a helmet during the day because of chronic tonic-clonic seizures."
  • E. "Using utensils with large, padded handles makes it easier for my child to feed himself."
Correct Answer: A,B,D,E

Rationale: ROM exercises, therapeutic massage, helmet use for seizures, and adaptive utensils indicate appropriate care for spastic CP.

The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately?

  • A. Localized edema and discoloration occurring hours after the injury.
  • B. Generalized weakness and increasing sensitivity to touch.
  • C. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain.
  • D. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.
Correct Answer: C

Rationale: Absent pulses and increasing pain suggest compartment syndrome or arterial occlusion, requiring urgent HCP notification. Edema is expected, weakness is nonspecific, and pain relief is positive.

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