C HAPTER 39: P ROMOTING M USCULOSKELETAL
F UNCTION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The nurse placing a patient following knee replacement surgery into a
continuous passive motion (CPM) machine has the responsibilit y to:
a. raise the head of the bed to 30 to 45 degrees.
b. set the proper flexion and extension limits.
c. elevate the machine at the foot of the bed on one pillow.
d. keep the operated knee warm.
ANS: B
The nurse is responsible for securing the limb in the machine and
setting the proper flexion and extension limits ordered by the primary
care provider.
DIF: Cognitive Level: Application REF: p. 797 OBJ:
Theory #4 TOP: Continuous Passive Motion Machine
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Reduction of Risk
2. A nurse performing a head to toe neurovascular check on a patient in a
long leg cast notes an indication of altered perfusion as evidenced by:
, a. capillary refill of 3 seconds.
b. palpable peripheral pulses.
c. warm feet and hands.
d. numbness of distal limb.
ANS: D
Pallor, numbness, or cyanosis indicates reduced circulation. Other
adverse changes are coolness, diminished or absent pulses, and
possibl y pain.
DIF: Cognitive Level: Anal ysis REF: p. 799|Box 39 -3
OBJ: Theory #5 TOP: Neurovascular Impairment
KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. The nurse assesses a patient as having delayed capillary refil l if the
blanching lasts longer than:
a. 1 second.
b. 2 seconds.
c. 3 seconds.
d. 5 seconds.
ANS: D
Normal capillary refill should be within 3 seconds for the general
population and within 5 seconds for an older adult.
, DIF: Cognitive Level: Comprehension REF: p. 799|Box 39-3
OBJ: Theory #5 TOP: Neurovascular Assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX:
Health Promotion and Maintenance: Prevention and Earl y
Detection of Disease
4. A patient has just had a leg cast applied with plaster of Paris. The nurse
can best reduce the incidence of edema by:
a. elevating the leg on one to two pillows.
b. petaling the edges of the cast.
c. placing the patient in high Fowler’s position.
d. speeding the drying with a hair dryer.
ANS: A
Elevating the leg to heart l evel (one or two pillows) helps reduce
edema formation.
DIF: Cognitive Level: Application REF: p. 792 OBJ:
Theory #2 TOP: Casts KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrit y:
Reduction of Risk
5. A nurse is appl ying an elasticized bandage to the leg of a patient. To
perform this procedure correctl y, the nurse should:
a. face the patient and wrap from proximal to distal.
b. adjust the pressure or tension as needed.
c. use metal clips to secure the wrap.
d. overlap turns of the ba ndage equall y.
F UNCTION
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The nurse placing a patient following knee replacement surgery into a
continuous passive motion (CPM) machine has the responsibilit y to:
a. raise the head of the bed to 30 to 45 degrees.
b. set the proper flexion and extension limits.
c. elevate the machine at the foot of the bed on one pillow.
d. keep the operated knee warm.
ANS: B
The nurse is responsible for securing the limb in the machine and
setting the proper flexion and extension limits ordered by the primary
care provider.
DIF: Cognitive Level: Application REF: p. 797 OBJ:
Theory #4 TOP: Continuous Passive Motion Machine
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Reduction of Risk
2. A nurse performing a head to toe neurovascular check on a patient in a
long leg cast notes an indication of altered perfusion as evidenced by:
, a. capillary refill of 3 seconds.
b. palpable peripheral pulses.
c. warm feet and hands.
d. numbness of distal limb.
ANS: D
Pallor, numbness, or cyanosis indicates reduced circulation. Other
adverse changes are coolness, diminished or absent pulses, and
possibl y pain.
DIF: Cognitive Level: Anal ysis REF: p. 799|Box 39 -3
OBJ: Theory #5 TOP: Neurovascular Impairment
KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. The nurse assesses a patient as having delayed capillary refil l if the
blanching lasts longer than:
a. 1 second.
b. 2 seconds.
c. 3 seconds.
d. 5 seconds.
ANS: D
Normal capillary refill should be within 3 seconds for the general
population and within 5 seconds for an older adult.
, DIF: Cognitive Level: Comprehension REF: p. 799|Box 39-3
OBJ: Theory #5 TOP: Neurovascular Assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX:
Health Promotion and Maintenance: Prevention and Earl y
Detection of Disease
4. A patient has just had a leg cast applied with plaster of Paris. The nurse
can best reduce the incidence of edema by:
a. elevating the leg on one to two pillows.
b. petaling the edges of the cast.
c. placing the patient in high Fowler’s position.
d. speeding the drying with a hair dryer.
ANS: A
Elevating the leg to heart l evel (one or two pillows) helps reduce
edema formation.
DIF: Cognitive Level: Application REF: p. 792 OBJ:
Theory #2 TOP: Casts KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrit y:
Reduction of Risk
5. A nurse is appl ying an elasticized bandage to the leg of a patient. To
perform this procedure correctl y, the nurse should:
a. face the patient and wrap from proximal to distal.
b. adjust the pressure or tension as needed.
c. use metal clips to secure the wrap.
d. overlap turns of the ba ndage equall y.
