Nclex-PN Musculoskeletal Exam with Verified Solutions 2024/2025Nclex-PN Musculoskeletal Exam with Verified Solutions 2024 The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is

Nclex-PN Musculoskeletal Exam with Verified Solutions 2024 The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? - Answer -Stay with the person and encourage the person to remain still. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? - Answer -Immobilize the leg before moving the client. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? - Answer -Provides comfort by reducing muscle spasms and provides fracture immobilization The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? - Answer -Serous drainage The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? - Answer -Check the client's alignment in bed. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? - Answer -Performing active range of motion (ROM) to the right ankle and knee The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? - Answer -Presence of a "hot spot" on the cast A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? - Answer -Impaired tissue perfusion The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? - Answer -Elevate the leg on pillows continuously for 24 to 48 hours. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? - Answer -Petaling the cast edges with adhesive tapeThe nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. - Answer - Keep the cast and extremity elevated. The cast needs to be kept clean and dry. Allow the wet cast 24 to 72 hours to dry. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? - Answer -8 inches to the front and side of the client's toes The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? - Answer -Moves the cane when the right leg is moved The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? - Answer -Elevating the limb and applying ice to the affected leg A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? - Answer -"I need to avoid getting the cast wet." A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement? - Answer -"I need to scrub the skin vigorously with soap and water." A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? - Answer -Left heel A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? - Answer -Slightly elevating the foot of the bed A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history? - Answer -Separation of wound edges A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? - Answer -"It is a normal response and indicates the presence of phantom limb sensation." The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that