Chapter 39: Promoting Musculoskeletal Function My Nursing Test Banks

Chapter 39: Promoting Musculoskeletal Function

Test Bank

MULTIPLE CHOICE

1. The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat:

a.

low oxygen saturation.

b.

atelectasis.

c.

hypostatic pneumonia.

d.

respiratory alkalosis.

ANS: C

Hypostatic pneumonia is a result of decreased physical mobility and is the most common hospital-acquired disorder in immobilized patients.

DIF: Cognitive Level: Comprehension REF: p. 790 OBJ: N/A

TOP: Hypostatic Pneumonia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

2. The nurse explains that range-of-motion exercises are necessary so that movement improves venous circulation by:

a.

vasodilation.

b.

compression of muscles on venous walls.

c.

increased metabolism.

d.

maintaining strength in muscles.

ANS: B

The range-of-motion exercises mimic normal muscle movement, which compresses the venous walls as a support to venous circulation.

DIF: Cognitive Level: Comprehension REF: p. 791 OBJ: Theory #5

TOP: Psychosocial Effects of Immobilization

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: reduction of risk potential

3. A nurse enters the room of a patient who is in Bucks traction (skin traction). An error in the traction setup observed would be:

a.

feet resting against the foot of the bed.

b.

weights hanging free in the air.

c.

knee gatch raised.

d.

head of bed elevated 20 degrees.

ANS: A

Feet should not rest against the foot of the bed because this interrupts the counter traction.

DIF: Cognitive Level: Analysis REF: p. 793 OBJ: Clinical Practice #1

TOP: Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

4. The daughter of an elderly woman with a diagnosis of a fractured tibia asks why her mother is in Bucks traction. The nurses most informative response would be that Bucks traction:

a.

helps the bone heal more quickly.

b.

allows for large traction weights to reduce the fracture.

c.

does not cause skin disruptions.

d.

reduces muscle spasm that accompanies fractures.

ANS: D

Skin traction such as Bucks traction reduces muscle spasm that accompanies fractures.

DIF: Cognitive Level: Comprehension REF: p. 803, Skill 39-2

OBJ: Clinical Practice #1 TOP: Skin Traction

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

5. An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurses best intervention would be to:

a.

notify the charge nurse of possible infection.

b.

wipe off drainage with a damp wash cloth.

c.

assure the patient that such drainage is expected.

d.

cover the pin with several gauze pads and tape securely.

ANS: C

Clear fluid drainage from pin sites is expected. The fluid can be removed with a sterile swab.

DIF: Cognitive Level: Application REF: p. 793 OBJ: Clinical Practice #1

TOP: Anxiety Relative to Skeletal Traction

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: coping and adaptation

6. A patient who just underwent a left arm cast change to a synthetic fiberglass cast asks when the cast should be dry. The best response is that it should be hardened enough to be durable within:

a.

30 minutes.

b.

60 minutes.

c.

4 hours.

d.

24 hours.

ANS: A

A synthetic cast made of material such as fiberglass is hardened enough to be durable within 30 minutes. A plaster cast can take 24 hours or longer to dry.

DIF: Cognitive Level: Knowledge REF: p. 794 OBJ: Theory #2

TOP: Casts KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. When handling a freshly applied plaster cast while assisting a patient from stretcher to bed, the nurse should handle the cast using:

a.

fingertips and palms.

b.

palms only.

c.

fingertips and flat parts of fingers.

d.

palms and flat parts of fingers.

ANS: D

To prevent indentations in the cast that could lead to complications, the cast should be touched only with the palms and the flat parts of the fingers.

DIF: Cognitive Level: Comprehension REF: p. 801, Skill 39-1

OBJ: Theory #2 TOP: Casts KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

8. A patient who fractured a leg several weeks ago is scheduled for cast removal after he returns home. The nurse should explain to the patient to expect the skin underneath the cast to appear:

a.

moist and pink.

b.

dry and dirty.

c.

moist and white.

d.

dry and greenish.

ANS: B

The skin that was underneath the cast will appear dry and dirty because of accumulation of dead skin cells during the weeks that the cast was in place. Warm soapy water to wash and lotions to moisturize will help.

DIF: Cognitive Level: Comprehension REF: p. 795, Clinical Cues

OBJ: Clinical Practice #4 TOP: Home Care for Cast Removal

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

9. The nurse explains that an air-fluidized mattress would not be advocated for the patient with:

a.

a spinal cord injury.

b.

recurrent pressure ulcers.

c.

burns that have been newly grafted.

d.

severe arthritis.

ANS: A

Air-fluidized therapy is not recommended for patients with unstable spines or for those who are ambulatory.

DIF: Cognitive Level: Analysis REF: p. 796 OBJ: Theory #3

TOP: Air-Fluidized Mattress KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

10. The nurse points out that the major advantage of the low-air-loss mattress is that it reduces the incidence of:

a.

urinary stasis.

b.

friction.

c.

constipation.

d.

contractures.

ANS: B

The low-air-loss mattress reduces the incidence of skin injury from friction and sheer.

DIF: Cognitive Level: Comprehension REF: p. 796 OBJ: Theory #3

TOP: Low Air Loss Mattress KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

11. The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility 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 physician.

DIF: Cognitive Level: Application REF: p. 798, Steps 39-1

OBJ: N/A TOP: Continuous Passive Motion Machine

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

12. 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 possibly pain.

DIF: Cognitive Level: Analysis REF: p. 798, Box 39-3

OBJ: Theory #5 TOP: Neurovascular Impairment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: reduction of risk potential

13. The nurse assesses an elderly patient as having delayed capillary refill if the blanching lasts longer than _____ second(s).

a.

1

b.

2

c.

3

d.

5

ANS: D

Normal capillary refill should be within 3 seconds for the general population and within 5 seconds for the elderly.

DIF: Cognitive Level: Comprehension REF: p. 798, Box 39-3

OBJ: Theory #5 TOP: Neurovascular Assessment

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

14. 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 Fowlers position.

d.

speeding the drying with a hair dryer.

ANS: A

Elevating the leg to heart level (one or two pillows) helps reduce edema formation.

DIF: Cognitive Level: Application REF: p. 799 OBJ: Theory #2

TOP: Casts KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

15. A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, 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 bandage equally.

ANS: D

Turns of the bandage should be overlapped evenly. The wrap should be applied from distal to proximal, maintaining even pressure or tension. Metal clips could fall off in the bed and injure the patient; tape or pins should be used if the bandage does not have an adherent strip.

DIF: Cognitive Level: Application REF: p. 804, Box 39-4

OBJ: Theory #6 TOP: Bandages KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

16. A nurse applying a pressure bandage for a patient should terminate the wrap by a _____ turn.

a.

spiral reverse

b.

circular

c.

spiral

d.

figure-of-eight

ANS: B

A circular turn should be used to either anchor a bandage or terminate it.

DIF: Cognitive Level: Application REF: p. 804, Steps 39-2

OBJ: Theory #6 TOP: Bandages KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. A patient needs to have a triangular bandage applied. The nurse should position the sling so that the hand is _____ inches below the elbow.

a.

1

b.

2

c.

4

d.

6

ANS: C

The hand should be approximately 4 inches higher than the elbow.

DIF: Cognitive Level: Application REF: p. 806, Steps 39-3

OBJ: Theory #6 TOP: Bandages KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

18. When transferring a patient from bed to chair using a mechanical lift, the nurse should:

a.

put the bed in the lowest position.

b.

position the sling under the patient from the top of the head to the buttocks.

c.

lower the far bed rail.

d.

widen the stance of the lifts base and lock it.

ANS: D

The bed should be adjusted to working height with the far side rail raised. The sling is positioned so that it lies from the back of the head or shoulders to the mid-thigh. The base of the lift is widened to provide a good base of support and is locked for safety.

DIF: Cognitive Level: Application REF: p. 807, Skill 39-3

OBJ: Clinical Practice #6 TOP: Mechanical Lift

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment

19. A nurse is observing a patient in a skilled nursing facility using a walker. The nurse concludes that the walker is at proper height if the patients elbows are bent to which angle while the patient is upright and grasping the handgrips?

a.

5 to 15 degrees

b.

15 to 30 degrees

c.

30 to 45 degrees

d.

45 to 60 degrees

ANS: B

The height is correct if the patients elbow is bent at a 15-to-30 degree angle while standing upright and grasping the handgrips.

DIF: Cognitive Level: Comprehension REF: p. 808 OBJ: Clinical Practice #7

TOP: Use of a Walker KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. A nurse giving instructions to a patient who will be using stairs while ambulating with crutches will instruct the patient:

a.

Take off the rubber tips of the crutches while using stairs.

b.

Rest the axillae on the axillary bar of the crutch.

c.

Bring the good leg up first when going up stairs.

d.

Move the good leg and the crutches together.

ANS: C

The patient should bring the good leg up first when going up stairs on crutches. The affected leg and the crutches then follow. The rubber tips are left on at all times for safety. The axillae should never rest on the axillary bar of the crutch, because this could result in nerve injury.

DIF: Cognitive Level: Application REF: p. 811, Patient Teaching

OBJ: Clinical Practice #7 TOP: Crutch Walking

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

21. A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:

a.

left the brakes of the wheelchair unlocked.

b.

placed the patients feet centered on the footrests.

c.

placed slippers on the patient.

d.

left the patient with the lap robe tucked underneath.

ANS: A

The brakes should always be locked when a wheelchair is not in motion, and especially when someone is being assisted in and out of a wheelchair.

DIF: Cognitive Level: Analysis REF: p. 811 OBJ: Clinical Practice #7

TOP: Assisting a Patient in a Wheelchair

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

COMPLETION

22. The nurse is aware that the maximum weight that can be applied with a skin traction is ______ pounds.

ANS:

15

fifteen

The maximum weight that can be applied to a skin traction is 15 pounds.

DIF: Cognitive Level: Knowledge REF: p. 793 OBJ: Clinical Practice #2

TOP: Skin Traction KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

23. The nurse demonstrates a crutch walking technique by advancing the left crutch and the right foot and then the right crutch and the left foot. This is the _____ gait.

ANS:

two-point

The two-point gait advances the opposite foot to the crutch.

DIF: Cognitive Level: Comprehension REF: p. 810, Patient Teaching

OBJ: Clinical Practice #7 TOP: Two Point Gait

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. The nurse, in order to prevent the cast from chafing, will instruct the patient for home care to _______ the rough edges with adhesive tape.

ANS:

petal

Adhesive tape may be used to petal around the rough, crumbling edges of a cast to prevent chafing.

DIF: Cognitive Level: Application REF: p. 794 OBJ: Clinical Practice #4

TOP: Petaling KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

MULTIPLE RESPONSE

25. The nurse plans for an immobilized patient who suffered a cerebrovascular accident to be protected from skin disruption by the use of: (Select all that apply.)

a.

rubber sheets.

b.

alcohol rubs to the heels.

c.

sheepskin pads.

d.

water mattresses.

e.

pulsating air pads.

ANS: C, D, E

Sheepskin pads, water mattresses, and pulsating air pads help protect the immobilized patient from skin disruption.

DIF: Cognitive Level: Application REF: p. 796 OBJ: Theory #4

TOP: Pressure Relief Devices KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: reduction of risk potential

26. A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home teaching plan information relative to: (Select all that apply.)

a.

protecting the cast from soiling.

b.

easing itching under the cast by scratching with a bent coat hanger.

c.

grasping the cast over the leg to help in turning.

d.

using the spreader bar to turn the patient.

e.

turning frequently to the prone position.

ANS: A, C, E

A patient with a hip spica cast will not be able to walk and will require frequent turning by grasping the cast over the leg to help in the turning process. A challenge is protecting the cast from stool or urine soiling. The patient should be turned frequently, especially to the prone position.

DIF: Cognitive Level: Application REF: p. 794 OBJ: Clinical Practice #4

TOP: Hip Spica Cast KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

27. The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: (Select all that apply.)

a.

pressure injuries.

b.

loss of bone mass.

c.

urinary infection.

d.

pneumonia.

e.

permanent loss of function.

ANS: A, B, D, E

Immobilization can cause pressure injuries, loss of bone mass, pneumonia, and possible permanent loss of function of the immobilized part. Although urinary infections are common, immobility is not their cause.

DIF: Cognitive Level: Comprehension REF: p. 789 OBJ: Theory #1

TOP: Effects of Immobility KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

28. When cleaning the pins on a patient in skeletal traction, the nurse should: (Select all that apply.)

a.

spray pin insertion with antimicrobial solution.

b.

clean closest to the skin puncture site in a circular motion.

c.

slightly rotate each pin to prevent adhesion to the bone.

d.

secure ends of wire with cork or adhesive tape.

e.

accomplish care with clean technique.

ANS: B, D

Pins should be cleansed with a sterile swab starting at the skin puncture; the ends of the wire or pin can be secured with a piece of cork or adhesive tape. The process is performed with sterile technique.

DIF: Cognitive Level: Application REF: p. 793, Box 39-2

OBJ: N/A TOP: Pin Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

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