1. The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement
indicates that additional teaching is necessary?
o "I will concentrate on leaning forward as I carefully sit down in a chair." [55%]
o "I will do my leg raises and quadriceps and buttock isometric exercises 2-3 times a day." [23%]
o "I will use the sock puller that the therapist gave me when I get dressed." [2%]
o "My child got me a riser for the toilet seat at home. I hope my feet reach the floor!" [18%]
➢ To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of
flexion.
➢ Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support
while lowering themselves onto the seat and when rising from it.
➢ Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided.
➢ (Option 2) The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and
continues them for several months after discharge.
➢ These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and
standing positions.
➢ (Option 3) The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees
when dressing or putting on slippers, shoes, and socks.
➢ The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a
long-handled shoehorn.
➢ (Option 4) The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion
when getting on and off the toilet seat.
➢ Educational objective:
To avoid prosthesis dislocation following hip arthroplasty, key discharge teaching points include performing leg
exercises to strengthen the muscles around the hip and avoiding excessive hip flexion (>90 degrees) when sitting,
dressing, and toileting.
2. An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema,
deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action?
o Administer analgesia [12%]
o Apply an ice pack to the wrist [10%]
o Assess capillary refill and sensation [64%]
o Elevate the wrist above heart level [12%]
➢ A Colles' fracture is a type of wrist fracture (distal
radius fracture) that causes a characteristic dinner
fork deformity of the wrist. It usually occurs when
the client tries to break a fall with an outstretched
arm or hand, and lands on the heel of the hand.
➢ It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis.
➢ While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing
interventions should include:
▪ Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This
is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or
arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is
compromised, urgent reduction of the fracture is indicated.
▪ Administering analgesia to promote comfort (Option 1).
▪ Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2).
▪ Elevating the extremity on a pillow above heart level to reduce edema (Option 4).
▪ Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of
motion.
➢ Educational objective:
While a client with a traumatic wrist fracture is undergoing evaluation by the HCP in the ED to determine appropriate
treatment, the nurse assesses circulation, sensation, and movement of the affected hand, and then performs nursing
interventions to reduce pain and edema.
3. The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone
fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply.
o Confusion and restlessness
o Increasing pain despite the opioid analgesia
o Paresthesia of the affected extremity
o Petechiae over neck and chest
o Pulse oximeter showing hypoxia
➢ FES is a rare, but life-threatening complication
that occurs in clients with long bone and pelvis
fractures.
➢ It can also occur in nontrauma–related conditions,
such as pancreatitis and liposuction. It usually
develops 24-72 hours following the injury or
surgical repair.
➢ There are no specific diagnostic tests to identify
FES. However, the initial characteristic signs and
symptoms include:
▪ Respiratory problems (eg, dyspnea,
tachypnea, hypoxemia) after a fat embolus
travels through the pulmonary circulation and
lodges in a pulmonary capillary, leading to
impaired gas exchange and acute respiratory
failure. This pathophysiology is similar to that
of a pulmonary embolus (Option 5).
▪ Neurologic changes (eg, altered mental status,
confusion, restlessness), which occur due to
cerebral embolism and hypoxia (Option 1).
▪ Petechial rash (eg, pin-sized purplish spots that
do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This
defining characteristic differentiates a fat embolus from a PE (Option 4).
▪ Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction.
➢ (Options 2 and 3) Increasing, severe pain unrelieved by opioid analgesia or pain that is disproportionate to the injury
and paresthesia (eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of
compartment syndrome.
➢ Educational objective:
FES presents with a triad of respiratory distress, mental status changes, and petechial skin rash. Fever and
thrombocytopenia can also be present.
4. The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the
following instructions should the nurse include? Select all that apply.
o Assess the residual limb daily for redness or irritation.
o Keep limb socks and elastic wraps clean and dry.
o Lie on your stomach three times a day for 30 minutes.
o Massage the residual limb with lotion each day.
o Wash the residual limb daily with soap and water.
➢ Residual limb care following an above-knee amputation (AKA) or a below-knee amputation (BKA) is an important
component of rehabilitation and focuses on maintaining skin integrity, controlling pain, preventing infection,
and restoring mobility.
➢ It is also important for the nurse to consider that the client may experience grief due to disturbed body image.
➢ The nurse should include the following residual limb care instructions when discharging a client after an AKA or BKA:
▪ Clean the limb by washing it daily with soap and warm water. Thoroughly dry after washing to prevent skin
maceration (Option
▪ Thoroughly inspect the limb for signs of infection (eg, redness) and areas that may be at risk for infection (eg,
irritation, skin breakdown) (Option 1).
▪ Keep limb socks, wraps, and appliances/prostheses clean and dry (Option 2).
▪ Perform daily range-of-motion exercises to improve muscle strength and mobility.
➢ Hip flexion contractures are a common complication during the recovery process. Nurses should teach clients to lie
prone several times each day and to avoid sitting in a chair for ≥1 hour (Option 3).
➢ (Option 4) Clients should be taught to avoid applying potential irritants (eg, alcohol, lotion, powder) to the residual
limb, unless prescribed by the health care provider. This reduces the risk of skin breakdown and infection.
➢ Educational objective:
Clients who have undergone lower limb amputation should be taught to wash the residual limb daily with warm water
and soap; inspect the limb for redness or irritation; keep limb socks, wraps, and appliances clean and dry; and lie prone
several times daily to prevent hip contractures.
5. The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which
assessment findings would the nurse most likely expect? Select all that apply.
o Ecchymosis over the thigh and hip
o Groin and hip pain with weight bearing
o Internal rotation of the affected extremity
o Muscle spasm around the affected area
o Shortening of the affected extremity
➢ The most common clinical manifestations of hip fractures include:
▪ Ecchymosis and tenderness over the thigh and hip – occur from
bleeding into the surrounding tissue as the femur is very vascular
and a fracture can result in significant blood loss (>1000
mL) (Option 1)
▪ Groin and hip pain with weight bearing (Option 2)
▪ Muscle spasm in the injured area – occurs as the muscles
surrounding the fracture contract to try to protect and stabilize the
injured area (Option 4)
▪ Shortening of the affected extremity – occurs because the
fracture can reduce the length of the bone and the muscles above
the fracture line pull the extremity upward (Option 5)
▪ Abduction or adduction of the affected extremity depending on
location and mechanism of injury.
➢ (Option 3) The affected extremity is usually externally rotated.
➢ Educational objective:
The characteristic clinical manifestations of most hip fractures
include external rotation, abduction, muscle spasm, and shortening of
the affected extremity.
6. A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for
which finding is most important?
o Biceps muscle spasm [14%]
o Forearm swelling [22%]
o Hand and wrist weakness [35%]
o Shoulder range of motion [26%]
➢ Excessive and prolonged pressure on the axillae can cause
localized damage to the radial nerve at the axilla.
➢ This leads to a reversible condition known as crutch
paralysis, or palsy, which manifests as muscle weakness
and/or sensory symptoms (tingling, numbness) of the arm,
wrist, and hand.
➢ It is caused by crutches that are too long or by leaning on the
top of the crutches when ambulating.
➢ Therefore, clients are taught to support body weight on the
hands and arms, not the axillae, when ambulating to ensure
that there is a 1-2 in (2.5-5 cm) space between the axilla and
the axilla crutch pad. Crutches should be checked for proper
length.
➢ (Option 1) Triceps muscle spasm can occur due to increased
muscle use, especially in clients with decreased upper body
strength. Triceps and biceps muscle spasms are not
complications associated with crutch walking.
➢ (Option 2) Forearm swelling is not a common complication
associated with crutch walking. In rare cases, arterial
obstruction can cause ischemic symptoms.
➢ (Option 4) Restricted shoulder range of motion is not a
major complication of crutch use.
➢ Educational objective:
Clients are taught to support their body weight on the hands
and arms, not the axillae, when ambulating with
crutches. Prolonged and continual excessive pressure on the axillae can damage the radial nerve, resulting in crutch
paralysis - muscle weakness and/or sensory symptoms over the forearm, wrist, and hand.
7. The nurse is caring for a woman with obesity who is 3 days postoperative total hip joint replacement. Which laboratory
value is of greatest concern and should be reported to the health care provider (HCP) immediately?
o Blood urea nitrogen (BUN) 22 mg/dL (7.9 mmol/L) [10%]
o Glucose 158 mg/dL (8.7 mmol/L) [7%]
o Hematocrit 33% (0.33) and hemoglobin 11 g/dL (110 g/L) [10%]
o White blood cell count (WBC) 16,000/mm3 (16.0 ×109/L) [71%]
➢ Infection is a major complication associated with joint replacement surgery.
➢ A client with obesity (body mass index ≥30 kg/m2) is at even greater risk for infection due to inadequate tissue
oxygenation as the vascularity of adipose tissue is decreased.
➢ This client is also at increased risk for postoperative pneumonia because obesity can lead to impaired pulmonary
function, sleep apnea, and obesity hypoventilation syndrome.
➢ Leukocytosis can indicate a wound infection or postoperative pneumonia. Therefore, the increased WBC count
(>11,000 mm3 [11.0 ×109/L]) is of greatest concern and should be reported to the HCP immediately (Option 4).
➢ (Option 1) The BUN is slightly above the normal limits (6-20 mg/dL [2.1-7.1 mmol/L]) and is not the greatest concern.
➢ (Option 2) The glucose is elevated (normal, 70-110 mg/dL [3.9-6.1 mmol/L]). However, the recommended random
glucose level for hospitalized clients is <180 mg/dL (10 mmol/L); the recommended level before meals is <140 mg/dL
(7.8 mmol/L).
➢ Obesity is often associated with metabolic syndrome and insulin resistance, and the physiologic stress of surgery can
contribute to hyperglycemia as well.
➢ Although the nurse will report the glucose level and continue to monitor it, the level is not the greatest concern.
➢ (Option 3) Decreased hematocrit (normal adult female 35%-47% [0.35-0.47]), and hemoglobin levels (normal 11.715.5 g/dL [117-155 g/L]) are to be expected in a client who has undergone joint replacement due to blood loss during
the surgery. The nurse will continue to monitor these, but the current levels are not the greatest concern.
➢ Educational objective:
Infection is a major complication associated with joint replacement surgery, and clients with obesity are at even greater
risk. The nurse should notify the HCP immediately of any signs of postoperative wound infection (eg, leukocytosis,
fever, increased wound drainage, erythema, increased pain).
8. A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the
client's plan of care? Select all that apply.
o Assess for skin breakdown of the limb in traction
o Ensure adequate pain relief
o Keep the limb in a neutral position
o Perform frequent neurovascular checks on the limb in traction
o Reposition the client and use a wedge pillow
➢ Buck traction is a type of skin traction used to immobilize
hip fractures and reduce pain and spasm until the client can
undergo surgical repair of the fracture.
➢ A traction boot is applied to the leg, below the fracture
site. A weight gently and continuously pulls on the leg and
hip, helping maintain alignment of the limb.
➢ The nurse should ensure that the traction boot is fitted
properly and that the limb remains straight in a neutral
position (Option 3).
➢ Skin traction exerts pressure on nerves, blood vessels, and soft
tissue. The nurse should frequently assess neurovascular
status (eg, pulse, capillary refill, color, temperature, sensation,
movement) and skin integrity in the limb to which the boot is
applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored
closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2).
➢ (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury.
➢ Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of
traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise.
➢ Educational objective:
Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired
surgically. The nurse caring for a client in Buck traction should frequently assess the neurovascular status and skin
integrity of the affected limb and maintain it in a straight, neutral position.
9. The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports
"numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3
seconds in the right great toe. Which action should the nurse take?
o Ask if the client wants pain medication for the "numbness and tingling" [1%]
o Ask the client if the "numbness and tingling" were present before surgery [57%]
o Continue assessment by observing the surgical dressing [18%]
o Notify the health care provider (HCP) immediately [22%]
➢ Numbness and tingling in both lower extremities are classic examples
of neuropathic pain. The common causes of bilateral peripheral
neuropathy include the following:
▪ Diabetic neuropathy – most common; distribution is usually
sock-and-glove pattern
▪ Autoimmune neuropathy – Guillain-Barré syndrome
▪ Toxic neuropathy – alcohol use
➢ Establishing that the sensations the client is experiencing were
present before surgery indicates whether this is a complication of
surgery. Because the sensation is bilateral and the surgery was on the
right knee, the "numbness and tingling" are probably baseline
diabetic neuropathy. This should be confirmed by gathering more
information from the client (Option 2).
➢ (Option 1) Diabetic neuropathy is not usually treated with traditional
post-surgical medications such as opioids.
➢ Medications for diabetic neuropathy are usually given on a fixed,
timed schedule and include duloxetine, pregabalin, amitriptyline, and
gabapentin.
➢ If the client uses an as-needed medication, it is important to ask for more information before administering it. The client
should be asked whether the pain is baseline and what medication is taken.
➢ (Option 3) The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client
further would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not
indicate a more serious situation.
➢ (Option 4) It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate
sufficient blood flow to the extremities.
➢ Educational objective:
The nurse should assess for causes of pain and rule out serious complications as part of a pain assessment. Sensations
of "numbness and tingling" indicate diabetic neuropathy but should be confirmed as baseline for the client before
continuing the assessment.
10. A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires
the registered nurse to intervene?
o Elevating a client's residual limb on a pillow 1 day after above-the-knee amputation [38%]
o Placing an abductor pillow between a client's legs after total hip replacement [7%]
o Positioning a client with Buck traction supine with the foot of the bed raised [41%]
o Using pillows to raise a client's extremity following cast placement [12%]
➢ To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be
elevated, especially after 24 hours.
➢ Instead, edema should be managed using a figure eight compression bandage.
➢ The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too
tightly.
➢ Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30
minutes 3 or 4 times a day.
➢ (Option 2) Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip
in a straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or
cross the legs or ankles.
➢ (Option 3) Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected
extremity and a prescribed weight pulls the limb into traction.
➢ The client is typically placed in supine position with the foot of the bed raised to maintain countertraction.
➢ (Option 4) After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to
increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated
if compartment syndrome develops.
➢ Educational objective:
Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a
day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated
as this will promote flexion contractures.
11. The nurse is assigned to care for a client who had a total hip replacement an hour ago. Which of the following should the
nurse assess first?
o Amount of drainage in suction drainage device [28%]
o Client's level of pain and last dose of pain medication [20%]
o Proper placement of the abduction pillow [45%]
o Urine in the catheter bag for presence of cloudiness or pus [5%]
➢ Common complications following total hip replacement are bleeding, prosthesis dislocation, deep vein thrombosis, and
infection.
➢ Total joint replacements carry a risk of serious blood loss; therefore, the nurse should check the drainage device and
dressing frequently to monitor blood loss, especially during the first several postoperative hours.
➢ (Option 2) Pain is typically controlled via a patient-controlled analgesia device with a programmed dosage and
lockout. The client's level of pain should be assessed, but assessing for hemorrhage is the priority.
➢ (Option 3) Following total hip replacement, the client will have an abduction pillow between the legs to prevent
adduction of the affected leg.
➢ Adduction of the leg could potentiate dislocation of the prosthesis. It is important that the client not flex the affected hip
more than 90 degrees, as this could dislocate the prosthesis.
➢ Therefore, the client should be provided elevated toilet seats and chairs that do not recline.
➢ The nurse should assess for signs of hip dislocation, including shortening and internal rotation of the leg.
➢ Although providing an abduction pillow is important, assessing for hemorrhage is the priority.
➢ (Option 4) Assessment of the urine in a postoperative client's catheter bag is important but is not priority in this
situation.
➢ Educational objective:
Orthopedic surgeries, particularly total hip replacement, can cause significant blood loss. Assessing the dressing and
drainage device is a priority over positioning an abduction pillow and evaluating the client's pain and quality of urine.
12. A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant,
severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear
dusky. What are the nurse's appropriate actions? Select all that apply.
o Apply a heating pad and encourage range-of-motion exercises
o Assess the temperature and movement of the fingers
o Elevate the arm on pillows above the level of the heart
o Notify the health care provider
o Reassure the client, document findings, and reassess in 1 hour
➢ Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal
to the injury. It results from either decreased compartment size (restrictive dressings, splints, or casts) or increased
pressure within the compartment (bleeding, inflammation, and edema).
➢ Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include
diminished/absent pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this
condition can lead to loss of limb function, paralysis, and tissue necrosis.
➢ The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4).
➢ Removal of tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure.
➢ (Option 1) Heat should not be applied to a client experiencing altered sensation, as it may burn the client. Active range
of motion will not resolve compartment syndrome and delays needed care.
➢ (Option 3) Elevating the arm on pillows and providing additional analgesia may help reduce symptoms but may also
reduce perfusion of the extremity. Instead, the extremity should be positioned at the level of the heart.
➢ (Option 5) Documenting findings is important. However, reassurance and reassessment 1 hour later without immediate
intervention delays needed care.
➢ Educational objective:
Compartment syndrome is caused by decreased blood flow to the tissue distal to the injury and can cause ischemic
necrosis. Acute compartment syndrome following surgery or casting is potentially limb-threatening and requires
emergency evaluation by a health care provider.
13. A client with rheumatoid arthritis (RA) tells the home health nurse, "My fatigue and stiffness are getting worse and I'm
having trouble moving around, especially in the morning. What can I do?" Which intervention would be best for the client
to perform first?
o Eat a high-calorie carbohydrate breakfast immediately after awakening [0%]
o Perform range of motion exercises before getting out of bed [43%]
o Take a warm shower or bath immediately after getting out of bed [39%]
o Take prescribed nonsteroidal anti-inflammatory medication on awakening [16%]
➢ Prolonged morning stiffness of the affected joints is a major complication of rheumatoid arthritis (RA).
➢ Taking a warm shower or bath first on awakening would be the best intervention as heat decreases stiffness and
promotes muscle relaxation and mobility.
➢ With increased flexibility and decreased stiffness, the client's usual morning activities (eg, dressing, making breakfast)
would be easier and less painful and tiring to perform.
➢ (Option 1) A balanced diet and weight control are important. Diet and exercise should be proportional, especially
during periods of disease exacerbation and decreased physical activity as excess weight exerts additional stress on
weight-bearing joints.
➢ (Option 2) Range of motion exercises are more effective after a warm bath or shower as stiffness is decreased, thereby
improving flexibility.
➢ (Option 4) Nonsteroidal anti-inflammatory drugs (NSAIDS) (eg, naproxen [Naprosyn], ibuprofen [Motrin]) should not
be taken on an empty stomach as these can cause gastrointestinal upset. If prescribed once daily, these are probably best
taken in the evening after dinner as RA symptoms slowly increase during the night and worsen in the morning.
➢ A higher serum drug level in the morning can help to reduce inflammation and stiffness. Therefore, if NSAIDS are
prescribed twice daily, taking them in the morning with breakfast and in the evening with dinner is recommended.
➢ Educational objective:
A nonpharmacologic intervention such as taking a warm bath/shower or applying heat can decrease morning stiffness
and improve flexibility in clients with RA.
14. A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and
muscle pain. The nurse should implement which prescription first?
o ECG [22%]
o IV morphine 2 mg [5%]
o Normal saline bolus [50%]
o Urine sample [21%]
➢ Rhabdomyolysis occurs when muscle fibers are released into the
blood, usually after an intense muscle injury from exercise, heat
stroke, or physical trauma.
➢ Acute renal failure can occur when elevated myoglobin (protein
found in muscle tissue) levels overwhelm the kidneys' filtration
ability.
➢ The nurse's priority is to prevent kidney damage using rapid IV
fluid resuscitation to flush the damaging myoglobin pigment from
the body. Common signs of rhabdomyolysis are dark, oftentimes
bloody urine, oliguria, and fatigue.
➢ (Option 1) With muscle injury, intracellular potassium is released
into the circulation, potentially causing dangerous
arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium
levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the
injured muscles.
➢ Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying
expected problem is a priority over testing to identify the problem.
➢ (Option 2) Pain and symptom management should be a high priority but should not take precedence over preserving the
client's kidney function.
➢ (Option 4) Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not
take priority over treatment to preserve kidney function.
➢ Educational objective:
Rhabdomyolysis is a medical emergency caused by muscle injury that releases myoglobin into the bloodstream. The
nurse's priority when treating the client is to preserve kidney function by administering large volumes of IV fluid.
15. The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which
finding requires priority action?
o Blood-tinged stain on the inner aspect of the cast [13%]
o Capillary refill of 2 seconds on the affected extremity [4%]
o Mild swelling of toes on the right foot [16%]
o Pain of 9/10 an hour after a dose of morphine [65%]
➢ Neurovascular integrity should always be tested first after cast application by performing circulation, motor, and
sensory checks. The client should have no numbness or tingling.
➢ If pain is not relieved (especially with passive range of motion) by prescribed pain medication or is out of proportion
to the injury, the nurse should notify the health care provider (HCP).
➢ Permanent damage to the circulatory and nervous systems (compartment syndrome) can occur if this is not addressed
immediately (Option 4). Pallor, pulselessness, and paralysis are late signs of compartment syndrome.
➢ (Option 1) Blood stains on a cast after an open orthopedic surgical procedure are not unusual. The nurse should circle
the stains and mark the date and time on the cast so further bleeding can be easily visualized. However, rapid
enlargement of a stain needs to be reported to the HCP.
➢ (Option 2) The skin on the affected extremity should be pink and warm. When blanched, it should return to normal
color in <3 seconds.
➢ (Option 3) Mild swelling/edema of the toes can occur from cast pressure and can be reduced with leg elevation using
pillows. Increasing swelling should be reported to the HCP. Most clients report severe pain when the cause is
compartment syndrome, which is a priority.
➢ Educational objective:
Compartment syndrome is a limb-threatening emergency that can occur after fracture reduction. Neurovascular checks
should always be performed first. The client should not have numbness or tingling. If pain is not relieved (especially
with passive range of motion) by prescribed pain medication or is out of proportion to the injury, the nurse should notify
the health care provider.
16. A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does
the nurse expect to assess in this client? Select all that apply.
o Crepitus with joint movement
o Low-grade fever
o Morning stiffness lasting 10 to 15 minutes
o Pain exacerbated by weight-bearing activities
o Positive serum rheumatoid factor
➢ Osteoarthritis (OA) is a degenerative disorder of
the synovial joints (eg, knee, hip, fingers) that causes
progressive erosion of the articular (joint) cartilage and
bone beneath the cartilage.
➢ As the degenerative process continues, bone spurs
(osteophytes), calcifications, and ulcerations develop
within the joint space, and the "cushion" between the
ends of the bones breaks down.
➢ Clinical manifestations of OA of the knee include:
▪ Pain exacerbated by weight-bearing
activities: Results from synovial inflammation,
muscle spasm, and nerve irritation (Option 4)
▪ Crepitus, a grating noise or sensation with
movement that can be heard or palpated: Results
from the presence of bone and cartilage fragments
that float in the joint space (Option 1)
▪ Morning stiffness that subsides within 30 minutes of arising (Option 3)
▪ Decreased joint mobility and range of motion
▪ Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse
➢ (Option 2) Low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory,
nonsystemic disorder. Occasional OA inflammation is limited to affected joints.
➢ (Option 5) Serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory
tests or biomarkers exist for OA.
➢ Educational objective:
Osteoarthritis is a degenerative disorder of the synovial joints that leads to progressive erosion of the articular (joint)
cartilage. Clinical manifestations include pain exacerbated by weight-bearing, crepitus, morning stiffness subsiding
within 30 minutes, decreased joint mobility and range of motion, and atrophy of supporting muscles.
17. A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse
assess first?
o Client who sustained a closed, incomplete ulnar fracture while playing sports [2%]
o Client with bilateral metacarpal fractures after falling out of bed [1%]
o Client with multiple myeloma who has a vertebral fracture and aching back pain [30%]
o Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation [65%]
➢ Joint dislocations may become orthopedic
emergencies because articular bone may compress
surrounding vasculature, causing limbthreatening distal ischemia (Option 4).
➢ When a joint is dislocated, the articular tissues, blood
vessels, and nerves are often traumatized by stretching.
➢ Signs of joint dislocation include pain, deformity,
decreased range of motion, and extremity paresthesia.
➢ The nurse should frequently assess neurovascular status
and provide analgesics until the dislocation can be reduced
and immobilized.
➢ (Option 1) In incomplete greenstick fractures, the bone
bends and cracks but remains in one piece.
➢ These fractures are most common in children, as their
bones are soft and flexible. The nurse should provide
analgesics and offer reassurance; however, the client with
neurovascular impairment should be assessed first.
➢ (Option 2) Fractures of the bones of the hand (ie,
metacarpals) are common in fall injuries, when the brunt of
the fall is borne against the hands and fingers, resulting in hyperflexion or hyperextension.
➢ The nurse should provide analgesics; however, the client with neurovascular impairment should be assessed first.
➢ (Option 3) Pathologic vertebral compression fractures and pain are expected in clients with multiple myeloma.
➢ These clients commonly experience fractures of the vertebral column and spinal processes as the cancer weakens and
decalcifies the vertebrae. This client should be evaluated next to rule out spinal cord involvement.
➢ Educational objective:
Joint dislocations may constitute an orthopedic emergency. Because articular tissues, blood vessels, and nerves are
stretched and compressed, neurovascular compromise may occur. Prolonged disruption of the vasculature and nerves
may cause permanent injury and even loss of the distal extremity.
18. The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement
indicates the need for additional teaching?
o "I have to give myself shots in the belly because my spouse is afraid of needles!" [31%]
o "I have to use a walker because I can't bear any weight on this knee yet." [52%]
o "I will call my health care provider if I get short of breath or sore or swollen below my knee." [5%]
o "The raised toilet seat makes it easier for me to get on and off the toilet by myself." [10%]
➢ The average hospital length of stay following total knee arthroplasty is 3-5 days.
➢ After the surgery, immediate initiation of physical therapy is a priority. An isometric quadriceps setting is initiated on
the 1st postoperative day. The client should be fully weight bearing by discharge.
➢ Clients use an assistive device (eg, walker, crutches, cane, grab bar, hand rails) to help them sit, rise safely from a sitting
to a standing position, and to negotiate steps (Option 2).
➢ A knee immobilizer is used to maintain extension during ambulation and at rest for about 4 weeks.
➢ (Options 1 and 3) Venous thromboembolism (eg, deep vein thrombosis [DVT], pulmonary embolism [PE]) following
knee arthroplasty is a major preventable complication.
➢ Anticoagulation with oral anticoagulants (rivaroxaban) or enoxaparin (Lovenox) injections is therefore prescribed for at
least 2 weeks after surgery.
➢ Ankle exercises, anti-embolic stockings, and frequent mobilization are prescribed as well.
➢ Clients are taught to recognize the warning signs and symptoms of DVT (eg, new swelling, tenderness, pain below the
knee) or PE (eg, shortness of breath, pleuritic chest pain).
➢ (Option 4) A raised toilet seat facilitates sitting on and rising from the toilet without over-bending the knee. Assistive
devices, such as a long-handled shoehorn, shower chair, or grab bar, are also helpful for client safety at home.
➢ Educational objective:
A client with total knee arthroplasty needs assistive devices (eg, walker, crutches) and a knee immobilizer to help
ambulation; the client should be fully weight bearing by discharge. Prophylactic anticoagulation and recognition of
postoperative complications (eg, DVT, PE) are also important.
19. The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of
scoliosis. Which instruction will the nurse include in the discharge teaching plan?
o Apply body lotion or powder under the brace to prevent skin irritation [6%]
o Avoid any exercises that require the use of spinal muscles [13%]
o Keep the brace on for all activities, including showering [11%]
o Wear a cotton t-shirt under the brace at all times [68%]
➢ The Boston brace, Wilmington brace, thoracolumbosacral
orthosis (TLSO) brace, and Milwaukee brace are used to
diminish the progression of deformed spinal curves in scoliosis.
➢ Braces do not cure the existing spinal deformities but do prevent
further worsening. These braces are also sometimes used for
clients who undergo spinal fusion.
➢ The braces are molded plastic shells worn around the trunk of the
body under the client's outer clothing.
➢ Due to the risk for skin breakdown, clients should wear a cotton
t-shirt under the brace to decrease skin irritation and absorb
sweat. Compliance is a major problem in most adolescents as
they are preoccupied with body image and appearance.
➢ Psychosocial issues (eg, body image, sense of control,
socialization) are very important to discuss. Many clients may
find it helpful to meet other individuals their age who also wear
the braces.
➢ (Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace.
➢ (Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout
treatment. Most prescribed bracing courses allow brace removal for such exercises.
➢ (Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal
curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never
shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown.
➢ Educational objective:
Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the
brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial
issues (eg, body image, socialization) should also be addressed to promote compliance.
20. The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which client statements
indicate a correct understanding of teaching? Select all that apply.
o "I should continue strenuous exercise during flare-ups."
o "I should include spine-stretching activities such as swimming."
o "I should quit smoking and perform breathing exercises."
o "I will sleep on a soft mattress to decrease my morning stiffness."
o "I will take the prescribed ibuprofen on an empty stomach."
➢ Ankylosing spondylitis (AS), an inflammatory disease
affecting the spine, has no known cause or cure.
➢ AS is characterized by stiffness and fusion of the axial joints
(eg, spine, sacroiliac), leading to restricted spinal mobility.
➢ Low back pain and morning stiffness that improve with
activity are the classic findings.
➢ Involvement of the thoracic spine (costovertebral) and
costosternal junctions can limit chest wall expansion, leading
to hypoventilation.
➢ The client with AS should:
▪ Promote extension of the spine with proper
posture, daily stretching, and spine-stretching exercises
(eg, swimming, racquet sports) (Option 2).
▪ Stop smoking and practice breathing exercises to
increase chest expansion and reduce lung
complications (Option 3).
▪ Manage pain with moist heat and NSAIDs.
▪ Take immunosuppressant and antiinflammatory medications as prescribed to reduce inflammation and increase mobility.
➢ (Option 1) It is best to rest during flare-ups. The client should delay exercise until the pain and inflammation are
under control.
➢ (Option 4) Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the
resulting deformity.
➢ (Option 5) Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset.
➢ Educational objective:
Ankylosing spondylitis is an inflammatory spinal disease characterized by back pain and morning stiffness that improve
with exercise/activity. Chest wall restriction is a serious complication. Treatment is targeted at reducing pain (eg, moist
heat, NSAIDs) and maintaining skeletal mobility (eg, proper posture, stretching, breathing exercises) to promote
activities of daily living.
21. A graduate nurse (GN) is caring for a client who underwent a total knee replacement 1 day earlier. Which intervention by
the GN would cause the supervising nurse to intervene?
o Applies a cold pack over the operative knee [17%]
o Initiates a continual passive motion device [20%]
o Obtains a leg-immobilizing device for ambulation [19%]
o Places a support pillow under the operative knee [43%]
➢ Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant.
➢ Knee arthroplasties are primarily performed for clients with severe pain or mobility impairment from arthritis.
➢ Following a knee arthroplasty, the nurse must plan care to reduce the client's risk of complications while promoting
comfort and recovery.
➢ Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility.
➢ To prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee
immobilizer or pillow placed under the lower leg or heel.
➢ Placing a pillow behind the knee causes joint flexion, which increases the risk of contracture (Option 4).
➢ (Option 1) Cold packs may be applied intermittently over the operative joint to reduce postoperative swelling and pain.
➢ (Option 2) Using a continual passive motion device, if prescribed, may improve range of motion through knee flexion
and extension and prevent contractures.
➢ (Option 3) Applying a leg immobilizer during ambulation provides support, maintains alignment, and prevents
dislocation of unstable operative joints.
➢ Educational objective:
Knee arthroplasty is the surgical replacement of the knee joint. Following a knee arthroplasty, the nurse should avoid
placing a pillow behind the client's operative knee due to the risk of contracture. Proper postoperative care includes
applying intermittent cold packs to reduce pain and edema, using a continual passive motion device for flexibility, and
obtaining a leg immobilizer for joint stability during ambulation.
22. The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the
risk for fat emboli?
o Administering prophylactic enoxaparin as prescribed [30%]
o Frequent use of incentive spirometry [7%]
o Minimizing movement of the fractured extremity [34%]
o Use of an intermittent pneumatic compression device [26%]
➢ Fat embolism syndrome (FES) is a life-threatening
condition that has no specific treatment. Therefore,
prevention, early diagnosis, and immediate
management of symptoms are critical.
➢ When a long bone is fractured, pressure within the bone
marrow leads to release of fat globules into the
bloodstream.
➢ These combine with platelets (fat embolus) and can
travel to the brain, lungs, and kidneys, leading to smallvessel occlusion and tissue ischemia. Therefore, early
stabilization of the injury and surgery as soon as
possible to repair long bone (eg, humerus, radius, ulna,
femur, tibia, fibula) fractures is recommended to reduce
further injury to soft tissue.
➢ The nurse should minimize movement of the injured
extremity to reduce the risk for fat emboli.
➢ (Options 1 and 4) Prophylactic anticoagulation, use of
intermittent pneumatic compression devices, and early
ambulation help reduce the risks for venous
thromboembolism (eg, deep vein thrombosis,
pulmonary embolus) but not fat emboli.
➢ (Option 2) Frequent use of incentive spirometry prevents atelectasis and pneumonia.
➢ Educational objective:
Minimizing movement of a fractured long bone and early stabilization of the injury with surgery reduce the risk for fat
emboli.
23. The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call
back first?
o Client who had a left total knee replacement 7 days ago and reports cramping pain in the left calf [65%]
o Client with a fractured wrist who reports severe itching under a cast that was applied 3 days ago [3%]
o Client with an ankle sprain who is using crutches and reports tingling in the forearm and fingers [21%]
o Client with an intact anterior cruciate ligament injury who reports tightness in the knee unrelieved with ice [10%]
➢ The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep
vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation.
➢ This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus
can lead to a pulmonary embolus, which is potentially life-threatening.
➢ (Option 2) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air
from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event.
➢ (Option 3) This client is most likely using the crutches incorrectly or they are not fitted correctly.
➢ Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This
symptom needs intervention, but it is not potentially life-threatening.
➢ (Option 4) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE
(rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may
require aspiration, but the condition is not potentially life-threatening.
➢ Educational objective:
Cramping calf pain following joint replacement surgery can indicate the presence of a venous thrombosis and needs
immediate intervention with diagnostic testing as the condition is potentially life-threatening.
24. The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to
"reach the itch." What is the nurse's priority action?
o Offer the client a straw to reach the itch instead of a lead pencil [1%]
o Perform a peripheral neurovascular check of the casted extremity [29%]
o Pour a generous amount of baby powder or corn starch in the cast to reach the itch [2%]
o Review appropriate itch relief technique using the cool setting of a hair dryer [67%]
➢ To relieve itching underneath a casted area, clients should use the cool setting of a hair dryer to direct air under the cast.
➢ Clients should never place any object, lotions, or powders in or around the casted area as skin irritation, injury, or
infection may occur.
➢ Signs and symptoms of infection (eg, sores, purulent drainage, foul odors) and persistent itching should be reported to
the health care provider.
➢ (Options 1 and 3) Nothing should be placed inside a cast due to the risk for injury and infection.
➢ (Option 2) The skin of the casted extremity should be assessed as the client could have damaged it by inserting a
pointed object.
➢ Regular neurovascular checks should be performed on a client with a new cast as the client is at risk for compartment
syndrome.
➢ However, there is no indication of peripheral vascular impairment (eg, changes in extremity color, temperature, or
pulse) or peripheral neurologic impairment (eg, loss of sensory or motor function) of the casted extremity; therefore, this
is not the priority at this time.
➢ Educational objective:
The client should be taught that nothing should be placed in a cast. Attempting to reach an itch with any instrument (eg,
pencil, coat hanger) or applying powder or lotion may cause skin breakdown and infection. Cool air from a hair dryer
may alleviate the itch.
25. The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which
instruction is appropriate to include in the teaching plan?
o Apply elastic compression hose to wrists [7%]
o Avoid use of caffeinated or tobacco products [21%]
o Perform repetitive hand exercises daily [16%]
o Wear a wrist immobilization splint [54%]
➢ Carpal tunnel syndrome (CTS) is pain and paresthesia of the
hand caused by median nerve compression within the carpal
tunnel at the wrist.
➢ Nerve compression can occur due to inflammation of the
tendons; narrowing or compression of the carpal tunnel; or
wrist flexion or extension.
➢ Symptoms of CTS are often exacerbated during sleep due to
prolonged and unintentional wrist flexion.
➢ Most clients with CTS can conservatively manage symptoms
with wrist immobilization splints (Option 4).
➢ Splinting and immobilization of the wrist (particularly during
sleep) reduces pain by preventing flexion or extension and
subsequent nerve compression. Clients with CTS may require
surgery to permanently relieve symptoms.
➢ (Options 1 and 3) Instructing clients to perform repetitive
hand exercises or wear elastic compression hose could worsen
symptoms of CTS by increasing median nerve compression.
➢ (Option 2) Although educating clients to avoid tobacco and
caffeinated products is appropriate to improve general health,
avoidance of such substances does not impact symptoms of
CTS.
➢ Educational objective:
Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by compression of a median nerve within the
carpal tunnel of the wrist. Clients with CTS are taught to wear wrist immobilization splints, particularly at night, to
prevent wrist flexion and subsequent nerve compression to reduce symptoms.
26. The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most
likely assess which of the following?
o Complete stiffness of the shoulder joint [10%]
o Paresthesia over the first 3½ fingers [8%]
o Shoulder pain with arm abduction [72%]
o Tenderness over the lateral epicondyle [8%]
➢ The rotator cuff is a group of 4 shoulder muscles and
tendons that attach to the humeral head. It allows for
rotation of the arm.
➢ A partial or full thickness rotator cuff tear can occur
gradually over time as a result of aging, repetitive use, or an
injury to the shoulder.
➢ It can also occur as a result of a sports injury involving
repetitive overhead arm motion (eg, swimming, tennis,
baseball, weight lifting).
➢ Characteristic symptoms of rotator cuff injury usually
include shoulder pain and weakness.
➢ Severe pain when the arm is abducted between 60 and 120
degrees (painful arc) is characteristic (Option 3).
➢ (Option 1) Restriction of active and passive ranges of
motion of the shoulder (complete stiffness) is seen with
frozen shoulder.
➢ (Option 2) Pain and paresthesia over the first 3½ fingers
suggest carpal tunnel syndrome.
➢ (Option 4) Tenderness over the lateral epicondyle is seen
with tennis elbow.
➢ Educational objective:
Rotator cuff injury involves a group of muscles and tendons in the shoulder. Characteristic symptoms of rotator cuff
injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120
degrees (painful arc) is characteristic.
27. The nurse is caring for a client who has just returned from external fixation device placement for stabilization of a fractured
femur. Which of the following interventions are appropriate to include in the client's plan of care? Select all that apply.
o Assess for increasing drainage from pin sites
o Check for loose pins and tighten them if loose
o Maintain bed rest until the device is removed
o Monitor pulses distal to the external fixation device
o Perform pin care with a sterile cleaning solution
➢ An external fixator is a device used to stabilize broken
bones; metal pins are placed through the tissue into the
bone and connect to a frame outside the skin.
➢ The nurse should monitor clients with external fixation
closely for signs of neurovascular compromise and pin
site infection, which can lead to osteomyelitis.
➢ When caring for clients with external fixation, the nurse
can help prevent infection and maintain extremity and
device integrity by:
▪ Assessing the pin sites regularly for new, increased,
and/or purulent drainage and checking the skin
surrounding the pins for erythema, warmth, pain, or
breakdown (Option 1)
▪ Assessing for signs of compartment
syndrome (eg, decreased pulses, coolness, pain,
numbness) (Option 4)
▪ Performing pin site care with a sterile cleaning
solution (eg, chlorhexidine, sterile normal saline)
and gauze (Option 5)
▪ Monitoring pins and device for loosening and
reporting to the health care provider (HCP) if they are loose
➢ (Option 2) The nurse should never manipulate loose pins but should instead notify the HCP immediately if loose pins
are noted on assessment.
➢ (Option 3) The nurse should promote early mobilization for clients with external fixation devices. Some clients may
begin walking with physical therapy the day after surgery.
➢ Educational objective:
When caring for clients with external fixation, the nurse should assess for signs of infection (eg, pin site drainage),
perform pin care with a sterile cleaning solution, assess for loose pins, monitor for signs of neurovascular impairment
(eg, decreased pulses, coolness), and promote early mobilization.
28. After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider
diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that
apply.
o Apply heat to reduce swelling during the first 24 hours
o Begin an exercise rehabilitation program when the pain subsides
o Elevate the leg above the heart level on 2 pillows
o Flex and dorsiflex the foot to prevent stiffness during the first 24 hours
o Take ibuprofen every 6 hours as needed
o Wrap the ankle with an elastic compression bandage
➢ A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes:
▪ Rest – Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care
provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required.
▪ Ice (cold, cryotherapy) – Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first
24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly
to the skin.
▪ Compression (eg, ACE wrap, splint) – Pressure/compression can help prevent edema and promote fluid
return (Option 6).
▪ Elevation – The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce
swelling by promoting fluid return (Option 3).
▪ Analgesia – Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours
as needed to relieve pain and reduce swelling (Option 5).
▪ Exercise rehabilitation program – This should be initiated as soon as possible after the injury (ie, when pain
subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option 2).
➢ (Option 1) Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30
minutes at a time to reduce swelling, with a cooldown between applications.
➢ (Option 4) Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged
to use the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with
some type of immobilizer (eg, brace, tape, splint).
➢ Educational objective:
Treatment for a sprained joint consists of Rest, Ice, Compression, and Elevation (RICE) for the first 24-48 hours
following the injury, mild analgesia with a nonsteroidal anti-inflammatory drug, and an exercise rehabilitation program
when pain subsides.
29. A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to
see first?
o Client reporting a tingling sensation [79%]
o Client reporting itching under the cast [0%]
o Client reporting pain of 5/10 on movement [1%]
o Client reporting throbbing on dependent positioning [17%]
➢ Clients with casted extremities after an acute injury are at risk for decreased peripheral perfusion due to increased
edema and a cast that restricts the skin's ability to expand.
➢ Together, these create an impingement of the circulation, or acute compartment syndrome (ACS), which is a medical
emergency.
➢ Nurses must prioritize clients demonstrating symptoms of ACS versus normal symptoms of a casted
extremity. Expected responses include mild to moderate edema, warmth or throbbing secondary to edema, pain on
movement or pain that improves with analgesics, itching (pruritus), and dry skin under the cast (Options 2, 3, and 4).
➢ High-priority symptoms that may indicate ACS include:
▪ Severe pain unresponsive to analgesics
▪ Immobility of digits
▪ Changes in sensation—tingling or numbness (indicating early nerve ischemia) (Option 1)
▪ Lack of pulses in distal extremity (not reliable for early ACS; absence of pulses indicates advanced/severe ACS)
▪ Cool and pale distal extremity
➢ Educational objective:
Expected symptoms of a casted extremity include mild to moderate edema, warmth or throbbing secondary to edema,
pain on movement or pain that improves with analgesics, itching (pruritus), and dry skin under the cast. Severe pain
unresponsive to analgesics and changes in limb sensations (tingling or numbness) may indicate compartment syndrome.
30. The nurse completes the preoperative assessment for a client scheduled for a total knee replacement today. Which
information should the nurse report to the health care provider (HCP) as soon as possible before the surgery?
o Has allergy to strawberries [19%]
o Is experiencing burning on urination starting yesterday [62%]
o Rates knee pain as a 9 on a 0-10 scale [2%]
o Stopped taking celecoxib 7 days ago [15%]
➢ A recent/current infection is a contraindication to total joint replacement surgery as a wound infection is more likely
to occur in a client with a preexisting infection.
➢ The nurse should report the new onset of burning on urination to the HCP.
➢ Burning could indicate the presence of a urinary tract infection.
➢ (Option 1) Allergy to strawberries is not a contraindication to the scheduled surgery. However, a latex allergy should
be documented.
➢ (Option 3) Severe knee pain is expected in a client undergoing a total knee replacement.
➢ (Option 4) Clients are directed to stop taking nonsteroidal anti-inflammatory drugs, including selective COX-2
inhibitors (eg, celecoxib [Celebrex]), 7 days before surgery to decrease the risk of intra- and postoperative bleeding.
➢ Educational objective:
A recent/current infection is a contraindication to elective total joint replacement surgery. Any clinical manifestation
that could indicate the presence of an infection should be reported to the HCP as soon as possible before the surgery.
31. The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements
made by the client would be the priority to assess further?
o "I am having problems extending my fingers since this morning." [37%]
o "I can't take any of the pain medicine because it makes me feel sick." [0%]
o "I have to scratch under the cast with a nail file because of the itching." [8%]
o "I noticed a warm spot on my cast, and a bad smell is coming from it." [53%]
➢ Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures.
➢ Swelling of antecubital tissue causes pressure within the
muscle compartment, restricting arterial blood
flow (brachial artery). The resulting ischemia leads to
tissue damage, wrist contractures, and an inability to
extend the fingers.
➢ A Volkmann contracture is a medical emergency that
can cause permanent damage to the extremity if left
untreated.
➢ Any restrictive dressing should be removed immediately,
and the health care provider (HCP) must be notified for
possible surgical intervention (eg, fasciotomy).
➢ (Option 2) The nurse should educate the client about
ways to prevent medication-related nausea, or the HCP
may consider switching pain medications. This would
be addressed last.
➢ (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity
and infection. This would be addressed third.
➢ (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has
been sticking objects inside to scratch the skin. This would be addressed second.
➢ Educational objective:
Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from
compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.
32. A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate
the need for further instruction? Select all that apply.
o "I will avoid foods high in calcium and phosphorus."
o "I will avoid going outside on sunny days."
o "I will decrease activity to prevent bone injury."
o "I will eat foods that are fortified with vitamin D."
o "I will use a cane to help me get around better."
➢ Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft,
and painful bones that can easily fracture or become deformed.
➢ In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable
for calcification of bone tissue.
➢ Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle
weakness.
➢ Nursing management focuses on:
▪ Implementing safety measures such as canes or walkers to prevent falls and injury (Option 5)
▪ Encouraging light to moderate activity, which can help promote bone strength and health (Option 3)
▪ Increasing dietary intake of:
▪ Calcium (eg, leafy green vegetables, dairy) (Option 1)
▪ Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains)
▪ Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also
recommended as it synthesizes vitamin D (Options 2 and 4)
▪ Taking over-the-counter or prescription supplemental vitamin D
➢ Educational objective:
Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification due to a vitamin D
deficiency. Nursing management focuses on implementing safety measures, encouraging activity, and increasing intake
of vitamin D, calcium, and phosphorus.
33. The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D
intake. Which lunch food is the best choice?
o Broiled chicken breast [14%]
o Canned sardines [42%]
o Peanut butter [14%]
➢ Osteopenia is more than normal bone loss for the client's
age and sex. Adequate dietary intake of calcium and
vitamin D is necessary to promote bone growth, prevent
resorption (bone loss), and prevent progression to
osteoporosis.
➢ Milk and milk products are the best sources
of calcium. However, other food sources are available for
individuals who are lactose intolerant.
➢ They include some fish (eg, sardines, salmon, trout), tofu,
some green vegetables (eg, spinach, kale, broccoli), and
almonds.
➢ Good food sources of vitamin D include egg yolks and oily
fish (eg, salmon, sardines, tuna).
➢ Canned sardines are the best choice as sardines are an
excellent source of calcium and vitamin D (Option 2).
➢ (Options 1, 3, and 4) These foods have only small amounts
of calcium per serving and no vitamin D.
➢ Educational objective:
Sardines are a good alternate dietary source of both calcium and vitamin D for individuals who are lactose intolerant.
34. The nurse is caring for a client who is 12 hours postoperative total hip replacement. Which nursing intervention is
appropriate to help prevent dislocation of the hip prosthesis?
o Instructing the client to cross the legs only at the ankles [1%]
o Maintaining the head of the bed at ≥60-90 degrees [2%]
o Placing an abductor pillow between the legs when turning the client [95%]
o Turning the client to the affected side to alleviate lateral muscle pulling [1%]
➢ Maintaining the affected extremity in alignment and avoiding
adduction and hip flexion are crucial in the initial postoperative
period following a total hip replacement to prevent the prosthesis
from becoming displaced or dislocated.
➢ Placing an abductor wedge pillow between the legs or placing 2-3
pillows between the knees when turning the client from side to side
prevents adduction of the operative extremity and reduces the
potential for hip prosthesis dislocation.
➢ (Option 1) The client is instructed not to cross the legs at the
ankles or knees to avoid adduction across the midline.
➢ (Option 2) The head of the bed should be maintained at ≤60
degrees to prevent excessive hip flexion (>90 degrees).
➢ (Option 4) The client should not sleep or be turned or positioned on the operative side unless directed by the health care
provider.
➢ When turning is necessary, the operative hip must be kept in abduction; pillows or a trochanter roll should support the
entire length of the leg.
➢ Educational objective:
Interventions to help prevent dislocation of a hip prosthesis following total hip replacement surgery include positioning
the client supine with the head of the bed elevated ≤60 degrees, with the affected extremity in a neutral position; placing
an abductor pillow wedge between the legs when turning the client to the unaffected side; and instructing the client to
avoid crossing the legs.
35. The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are
appropriate? Select all that apply.
o Cleans around the pin sites using sterile water
o Gently tightens the device screws if they become loose
o Holds the frame of the device when logrolling the client
o Places a small pillow under the head when client is supine
o Uses a blow-dryer on the cool setting to dry the vest when wet
➢ A halo external fixation device stabilizes a
cervical or high thoracic fracture when there is
insignificant damage to the ligaments or spinal
cord.
➢ Sensory and muscle function should be
monitored to determine any new deficits, and pin
sites should be regularly assessed for loose pins
or infection.
➢ Care for the client with a halo device includes:
▪ Cleaning pin sites with sterile solution (eg,
chlorhexidine, water) to prevent
infection (Option 1)
▪ Keeping the vest liner clean and dry (eg,
changing weekly or when soiled, using a cool
blow-dryer to dry) to protect the
skin (Option 5)
▪ Placing foam inserts under pressure points to
prevent pressure injury
▪ Placing a small pillow under the client's head
when supine to reduce pressure on the
device (Option 4)
▪ Keeping the correct-sized wrench available at all times in case of emergency
➢ (Option 2) Only the health care provider can adjust the pins.
➢ (Option 3) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the
screws to loosen or alter device alignment.
➢ Educational objective:
A halo external fixation device stabilizes a cervical or high thoracic fracture. The nurse should clean the pin sites with
sterile solution to prevent infection, reduce pressure on the halo device (eg, pillow under the head), keep the vest clean and
dry, and avoid holding the device frame while moving the client. Pins can be adjusted only by the health care provider.
36. A client who underwent open reduction and internal fixation of a right tibial fracture 10 hours ago reports worsening leg
pain that is unrelieved by PRN morphine. The nurse assesses that the client's right foot is cooler than the left. What is the
nurse's priority action?
o Administer the client's next dose of pain medication [0%]
o Assess the client's vital signs [12%]
o Maintain the extremity in a dependent position to promote blood flow [8%]
o Report these findings to the health care provider immediately [79%]
➢ Compartment syndrome (CS) results from compression of vascular structures by either external compression
(restrictive dressings/casts) or increased pressure within a compartment (bleeding, inflammation, and edema).
➢ After an injury or trauma (eg, surgery), the vessels surrounding the injury site are compressed by swelling muscle and
connective tissues.
➢ Muscle is encapsulated by a fibrous layer of fascia (ie, a compartment), which does not yield to swelling.
➢ Eventually, compression of tissues within the compartment restricts blood flow to the extremity.
➢ Signs of CS include the 6 Ps – pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias,
poikilothermia (coolness), and paralysis.
➢ The nurse should notify the health care provider immediately as CS is a limb-threatening emergency and requires
immediate surgery (fasciotomy) (Option 4).
➢ (Options 1 & 2) If the client is in pain, blood pressure and pulse may increase. However, assessing the client's vital
signs and giving the client more analgesic medication do not address the signs of CS.
➢ These actions delay emergency intervention. This client has enough evidence for suspicion of CS.
➢ (Option 3) If CS is suspected, the nurse should place the extremity at heart level to promote venous return and limit
swelling and loosen tight bandaging/casting material.
➢ If conservative measures fail, a fasciotomy (incision to open the fascia of the affected muscle compartment) may be
required to relieve the compression.
➢ Educational objective:
A client with signs of compartment syndrome (eg, pain, pallor, pulselessness) after a fracture or orthopedic surgery
should be evaluated by the health care provider (HCP) immediately. After notifying the HCP, the nurse should position
the affected extremity at heart level and loosen any restrictive bandaging/casting material.
37. The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home
management. Which statement by the client indicates comprehension of teaching?
o "Even with appropriate treatment joint damage and disability are inevitable." [16%]
o "My arthritis can be resolved if I can improve my diet and lose weight." [7%]
o "My methotrexate should be taken even when my joints aren't hurting." [61%]
o "When my joints hurt, I should rest frequently and try not to move them." [14%]
➢
➢
➢
➢
➢ Rheumatoid arthritis (RA) is a chronic,
relapsing autoimmune disorder causing painful inflammation
of synovial joints and fibrosis and stiffening of synovial membranes.
➢ Contracture of ligaments and joint remodeling may occur, resulting in
weakness and deformity.
➢ Clients with RA require education on prevention of disease
progression, including:
▪ Joint protection – Fibrosis from RA can shorten tendons and
ligaments when joints are flexed for prolonged periods. Body
aligners or immobilizers should be used when resting to keep
extremities straight (especially with advanced disease).
▪ Medications – RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate),
and clients should take their medication as prescribed regardless of symptoms (Option 3).
(Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic
drugs and joint protection.
(Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However,
obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause
weight loss. The nurse should ensure that clients with RA have access to adequate nutrition.
(Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of
motion exercises to prevent loss of function.
Educational objective:
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should
be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to
prevent joint contracture, and eat a balanced diet.
38. A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the
nurse assesses the client. Which finding should the nurse report to the health care provider immediately?
o Distended abdomen and absent bowel sounds [74%]
o Ecchymosis over the pelvic bones [18%]
o Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) [4%]
o Tenderness over the right heel [2%]
➢ Motor vehicle collisions and motorcycle crashes, followed by falls, are the most common mechanisms for pelvic
fractures.
➢ The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal
and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate). Therefore, when caring for a
client with a fractured pelvis, in addition to pain, the nurse should assess for internal hemorrhage (eg, abdominal
distension, vital signs, hematocrit, hemoglobin), paralytic ileus (eg, bowel sounds), neurovascular deficits (eg, extremity
circulation, sensation, movement), and abdominal and genitourinary organ injuries (eg, hematuria, urine output <0.5
mL/kg/hr).
➢ Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures.
➢ Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal
hematoma; these should be reported to the health care provider (HCP) (Option 1).
➢ (Options 2 and 4) Tenderness, bruising, and ecchymosis over the injured bones are expected and do not need to be
reported to the HCP. However, it would be important to communicate ecchymosis over the suprapubic area to the HCP
as this could indicate organ damage and internal hemorrhage.
➢ (Option 3) Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) are slightly lower than normal and may be
from the bleeding. During the acute hemorrhage, hemoglobin and hematocrit can be normal and will take some time to
reduce to significant levels. This is a second priority over actual bleeding findings.
➢ Educational objective:
The pelvis contains vascular structures and pelvic organs. Significant internal hemorrhage is common with pelvic
fractures and can manifest as abdominal distension and paralytic ileus.
39. The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further
clarification?
o Atorvastatin for hyperlipidemia in a client with angina pectoris [9%]
o Bupropion for smoking cessation in a client with emphysema [15%]
o Cyclobenzaprine for muscle spasms in a client with hepatitis [54%]
o Metronidazole for trichomoniasis in a client with Crohn disease [20%]
➢ Cyclobenzaprine (Flexeril) is a common, centrally acting skeletal muscle relaxant prescribed for muscle spasticity,
muscle rigidity, and acute or chronic muscle pain/injury.
➢ Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle
spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver
disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication
toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy).
➢ The prescription for a muscle relaxant would need to be clarified in a client with liver disease (Option 3).
➢ (Option 1) Atorvastatin (Lipitor) is a statin prescribed for hyperlipidemia. It is used for primary and secondary
prevention of cardiovascular disease and would not warrant further clarification when used in a client with angina
pectoris.
➢ (Option 2) Bupropion (Wellbutrin, Zyban) and varenicline (Chantix, Champix) are commonly prescribed for smoking
cessation. Both bupropion and varenicline can cause serious neuropsychiatric effects (eg, depression, suicide);
however, there is no contraindication for clients with emphysema.
➢ (Option 4) Metronidazole (Flagyl) is an antibiotic that can be used to treat a Trichomonas infection. There is no
contraindication for its use in clients with Crohn disease.
➢ Educational objective:
Like many medications, skeletal muscle relaxants (eg, cyclobenzaprine) are metabolized hepatically. In the presence of
hepatic impairment (eg, hepatitis), drug metabolism is reduced and results in the accumulation of medication in the
body, which leads to toxicity and serious adverse effects.
40. The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis
of the left knee. Which client statement indicates the need for further teaching?
o "I will hold the cane in my right hand." [17%]
o "I will move my left leg forward after moving the cane." [34%]
o "I will place the cane several inches in front of and to the side of my right foot." [25%]
o "My cane should equal the distance from my waist to the floor." [23%]
➢ Clients with one-sided weakness or injury, increased
joint pressure, or poor balance can use a cane to
provide support and stability when walking.
➢ Cane length should equal the distance from the
client's greater trochanter to the floor as incorrect
cane length can cause back injury.
➢ A cane measured from the waist would be too long to
provide optimal support (Option 4).
➢ Teaching points to assist a client in appropriate use of
a cane include:
a. Hold the cane on the stronger side to provide
maximum support and body alignment, keeping
the elbow slightly flexed (20-30 degrees) (Option
1).
b. Place the cane 6"-10" (15-25 cm) in front of and
to the side of the foot to keep the body weight on
both legs to provide balance (Option 3).
c. For maximum stability, move the weaker leg
forward to the level of the cane, so that body
weight is divided between the cane and the
stronger leg (Option 2). If minimal support is
needed, the cane and weaker leg are advanced
forward at the same time.
d. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the
weaker leg.
e. Always keep at least 2 points of support on the floor at all times.
➢ Educational objective:
Clients should hold the cane on the stronger side to provide maximum stability. Cane length should equal the distance from
the greater trochanter to the floor.
41. A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications
would help prevent future exacerbations? Select all that apply.
o Achieve and maintain a healthy weight
o Avoid foods containing protein
o Drink plenty of fluids
o Increase meat intake
o Limit alcohol consumption
➢ Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in
the blood.
➢ Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage.
➢ Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors
(eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in
uric acid control are often seen when weight lossis accompanied by dietary modifications (Option 1). Suggested
modifications include:
▪ Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option 3)
▪ Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood
(eg, sardines, shellfish)
▪ Limiting alcohol intake, especially beer (Option 5)
▪ Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates
➢ (Option 2) It is unpalatable and impractical to avoid all foods containing protein.
➢ The risk of developing gout increases with high dietary purineintake but not necessarily with protein intake.
➢ Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout.
➢ (Option 4) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate
them.
➢ Educational objective:
Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include
increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load.
42. The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures. Which client should the
nurse assess first?
o Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness [77%]
o Client who has purulent drainage oozing from a skeletal traction pin insertion site and a temperature of 100.8 F (38.2 C)
[4%]
o Client with a hip fracture receiving continuous IV saline with bilateral 2+ pitting leg edema and a blood pressure of
176/89 mm Hg [6%]
o Client with a rib fracture who is breathing at a rate of 23/min and is reporting 8/10 pain that is worse with inspiration
[11%]
➢ Clients with orthopedic injuries, particularly pelvic
and long bone injuries (eg, femoral fracture), may
develop a fat embolus.
➢ Fat emboli are thought to occur from the release of
fat globules (lipids) from bone marrow or the
systemic release of triglycerides into the
bloodstream following a mechanical insult.
➢ The circulating lipids can occlude small vessels in
the lungs (similar to pulmonary embolism), brain,
and skin, which impair circulation and oxygenation,
leading to:
▪ Respiratory distress syndrome (eg, dyspnea,
tachycardia, sudden and worsening chest pain,
hypoxemia, restlessness, anxiety)
▪ Altered mental status (eg, confusion, memory
loss)
▪ Petechial hemorrhages in the arms, chest, and/or
neck (Option 1)
➢ (Option 2) Purulent (eg, yellow, foul-smelling)
drainage from skeletal pins and fever may indicate
infection that could progress to
osteomyelitis. Treatment with antibiotics is required,
but this infection is not emergently life threatening.
➢ (Option 3) Pitting edema may occur in clients with impaired mobility (eg, hip fracture) and often relates to fluid volume
excess.
➢ Hypertension may also be related to fluid volume excess in clients receiving IV fluids. This client should be assessed next.
➢ (Option 4) Clients with rib fractures often take frequent, shallow breaths as they experience intense pain with
inspiration. Adequate pain control allows for deep breathing, which prevents buildup of secretions, atelectasis, and
pneumonia.
➢ Educational objective:
Clients with pelvic and long bone injuries are at risk for fat emboli, which can occlude small vessels in the lungs, brain, and
skin. Sign and symptoms include altered mental status (eg, restlessness), chest pain, respiratory distress, and petechial
hemorrhage.
43. A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral
secretions. What is the nurse's immediate action?
o Cut the wires [18%]
o Elevate the head of the bed [37%]
o Notify the health care provider [0%]
o Suction the mouth and oropharynx [43%]
➢ The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent
airway.
➢ If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via
the oral or nasopharyngeal route.
➢ If this intervention is ineffective, cutting the wires may be necessary.
➢ (Option 1) Cutting the wires can cause collapse of the fractured jaw and exacerbate the airway problem.
➢ This action is not the first priority unless the situation is an emergency (eg, acute respiratory distress, cardiopulmonary
arrest requiring intubation).
➢ A wire cutter must be taped to the head of the client's bed at all times, including during travel.
➢ (Option 2) Elevating the head of the bed is a preventive measure. Because the client is choking, the priority is suctioning
secretions to clear the airway.
➢ The nurse should also turn the client to the side if the client has excessive oral secretions or begins to vomit to decrease
the risk of aspiration.
➢ (Option 3) The nurse should intervene to maintain the airway before calling the health care provider.
➢ A prescription for nasogastric suction to decompress the stomach may be indicated to reduce the risk of vomiting.
➢ Educational objective:
Maintaining a patent airway is the priority for clients with mandibular fractures who are unable to open their mouths. If
choking occurs, the immediate intervention is to suction the mouth and oropharynx. If this is ineffective, cutting the wires
may be necessary.
44. The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured
hip and in Buck's traction. The RN intervenes when the GN performs which action?
o Elevates the head of the bed 45 degrees [29%]
o Holds the weight while the client is repositioned up in bed [41%]
o Loosens the Velcro straps when the client reports that the boot is too tight [27%]
o Provides the client with a fracture pan for elimination needs [1%]
➢ Buck's skin traction maintains proper alignment of an injured
body part by using weights to apply a continuous pulling
force.
➢ Appropriate actions for a client in Buck's skin traction
include:
▪ The client should be supine or in semi-Fowler's
position (maximum of 20-30 degrees). Elevating the
head of the bed more than 30 degrees would promote
sliding (Option 1).
▪ Regularly assess the neurovascular status and skin
integrity of the limb in traction. Loosen Velcro straps if
the boot is too tight as they can impair neurovascular
status and skin integrity; tighten the straps if the boot is
too loose as this can decrease effectiveness of the
traction. When a change is made in the application of the
boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3).
▪ Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and
provide comfort (Option 4).
▪
Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff
member should support the weight while the client is repositioned up in bed to prevent excessive pull on the
extremity (Option 2).
➢ Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a
fracture when continuous traction is needed and skin traction is not possible.
➢ Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening
situation.
➢ Educational objective:
To maintain effective pull and avoid interrupting traction, weights should be free-hanging at all times. Proper body
alignment should be maintained with the client supine or in semi-Fowler's position (maximum 30 degrees). The nurse
should monitor the neurovascular status and skin integrity of the limb in traction.
45. A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the
mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9
out of 10. What is the priority nursing intervention?
o Administer nasal oxygen at 3 L/min [7%]
o Administer opioids for pain [11%]
o Apply ice pack to face for 20 minutes each hour [4%]
o Suction the mouth and oropharynx [76%]
➢ A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture.
➢ The client drools due to inability to close the mouth from edema and misalignment of the jaw.
➢ Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway.
Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency.
➢ (Options 1, 2, and 3) Administration of nasal oxygen to facilitate breathing, administration of opioids to control pain, and
application of ice to reduce edema and help reduce pain are all appropriate interventions for this client. However, these are
not the priority interventions as the greatest threat to the client's survival is airway occlusion.
➢ Educational objective:
Common clinical manifestations in a client with a fractured mandible are pain, edema of the face and jaw, difficulty
speaking, drooling, and bleeding. Appropriate nursing interventions include oral suction to maintain airway patency,
administration of oxygen and analgesia, and application of ice to the face.
46. A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include
in the client's care plan to help prevent a hip fracture? Select all that apply.
o Calcium supplements
o Encourage bed rest
o Use of full bed rails during the night
o Vitamin D supplements
o Weight-bearing exercises
➢ The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture.
➢ Teaching to increase bone mineral density and prevent bone loss (resorption) includes:
▪ Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast])
▪ Calcium and Vitamin D supplementation (Options 1 & 4)
▪ Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls
▪ Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30
minutes, as increasing mechanical stress on bone increases bone density (Option 5)
➢ Interventions to prevent falls and resulting hip fracture include:
▪ Maintain bed in low and locked position
▪ Ensure that call light and personal belongings are within reach
▪ Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed
▪ Keep environment well-lit and free of clutter
➢ (Option 2) A client should not be placed on bed rest solely for the prevention of falls.
➢ Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis.
➢ The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone
resorption.
➢ (Option 3) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The
nurse should utilize bed alarms if the client is prone to getting out of bed without assistance.
➢ Educational objective:
An osteoporosis-related fall is the most common cause of hip fracture in the elderly. Interventions to reduce the risk of
fall and hip fracture include bisphosphonate medication, calcium and vitamin D supplements, mobility and weightbearing exercise, smoking cessation, and avoiding excessive use of alcohol.
47. A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an
ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse
reinforce? Select all that apply.
o Contact the clinic if any hot areas or foul odors develop in the cast
o Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
o Elevate the affected extremity above heart level for the first 48 hours
o Expect some numbness and tingling of the fingers during the first week
o Use only soft, padded objects to scratch the skin under the cast
➢
➢
➢
➢
➢ Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast
care include:
▪ Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1).
▪ Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2).
▪ Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3).
▪ Regularly perform isometric and range of motion exercises to prevent muscle atrophy.
(Option 4) The client should also be instructed to contact the health care provider about symptoms of impaired circulation
in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is
unrelieved by ice, elevation, and pain medication.
Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia
due to compression of blood vessels and nerves within the extremity's internal compartments.
(Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air
inside the cast with a hair dryer on the cool setting may help relieve itching.
Educational objective:
Cast care instructions include reporting foul odors or hot areas in the cast; preventing the cast from getting wet; elevating
the affected extremity above heart level for the first 48 hours; regularly exercising the affected extremity; and reporting
symptoms of impaired circulation (eg, numbness, tingling, pallor, coolness). Clients should never insert objects inside the
cast.
48. A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to
assess?
o Asymmetrical pain in the large weight bearing joints [11%]
o Low back pain and stiffness that is worse in the morning [18%]
o Pain, swelling, and redness of the great toe [3%]
o Symmetrical pain and swelling in the small joints of the hands [67%]
➢ Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory,
autoimmune condition of unknown origin that has periods of exacerbation
and remission.
➢ The body's immune system attacks the lining of the joints, leading to bone
erosion and joint deformity.
➢ Although there is no cure for the disease, early diagnosis and appropriate
treatment can help limit localized joint destruction and systemic organ
damage.
➢ Characteristic features of RA include the following:
▪ Symmetrical pain and swelling that initially affects the small joints of the hands and feet
▪ Morning joint stiffness that lasts from 60 minutes to several hours
▪ Elevated ESR and rheumatoid factor levels
➢ (Option 1) Asymmetrical pain in the weight bearing joints is characteristic of osteoarthritis. Crepitus, especially over
the knee joints, is also present in osteoarthritis.
➢ (Option 2 Low back pain and stiffness, worse in the morning and improving as the day progresses, is characteristic of
ankylosing spondylitis. RA typically does not involve the spine, except the cervical spine.
➢ (Option 3 Pain, swelling, and redness of one or more extremity joints (typically the great toe) are characteristic of
acute gout attack.
➢ Educational objective:
RA is a chronic, systemic, inflammatory, autoimmune disease of unknown origin. Early localized articular symptoms
include bilateral, symmetrical pain and swelling that initially affects the small joints of the wrists, hands, and feet and
morning joint stiffness that lasts at least an hour.
49. The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom
management. Which of the following client statements indicates a need for further teaching?
o "Daily range-of-motion exercises are important to keep my joints flexible." [4%]
o "I can use a moist heat pack to help with joint stiffness." [23%]
o "I should elevate my knees with pillows when I'm sleeping." [69%]
o "I will make sure to rest in between activities throughout the day." [2%]
➢ Rheumatoid arthritis (RA) is a chronic, autoimmune disorder characterized by inflammation and damage to synovial
joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness.
➢ Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living (eg,
toileting, bathing, dressing) and engage in routine tasks (eg, walking, opening doors).
➢ To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and
symptom-management strategies:
▪ Perform gentle range-of-motion exercises daily to maintain joint flexibility (Option 1).
▪ Apply moist heat packs to stiff joints and ice packs to painful joints (Option 2).
▪ Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities (Option 4).
➢ (Option 3) Clients with RA should be instructed to sleep and rest in a flat, neutral position.
➢ Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees
on pillows) increases the risk of contracture and may hasten decline of joint function.
➢ Educational objective:
Rheumatoid arthritis, a chronic autoimmune disorder, causes inflammation and remodeling of synovial joints, with
progressive loss of functional capacity. Clients should be educated to protect the joints with range-of-motion exercises,
allow for periods of rest during activities, use moist heat for stiffness and cold packs for pain, and sleep in a flat, neutral
position.
50. The nurse receives laboratory reports on 4 clients. Which report is most concerning and should be reported to the health
care provider?
o The client admitted with asthma exacerbation who has a PaCO2 of 32 mm Hg (4.26 kPa) [20%]
o The client diagnosed with chronic obstructive pulmonary disease whose latest arterial blood gas shows a PaO2 of 85
mm Hg (11.33 kPa) [11%]
o The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5 [7%]
o The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L) [59%]
➢ Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL (70 g/L) is very low
(normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]).
➢ This client needs to be assessed for any active bleeding as well as for respiratory and cardiac complications (eg, rapid
pulse, shortness of breath) resulting from the low hemoglobin level. The health care provider must be notified.
➢ (Option 1) Normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). Clients with asthma exacerbations, as well as those with
panic attacks, pulmonary embolism, and pneumonia, will have rapid breathing.
➢ In all of these conditions, this rapid breathing pushes more CO 2 out of lungs, with a mild decrease in PaCO2 as the
body's expected compensatory response. In these clients, retention of CO2 (or even normal PaCO2) is more dangerous
as it indicates respiratory muscle fatigue (failure) resulting in retention of PaCO 2.
➢ (Option 2) PaO2 >80 mm Hg (10.66 kPa) is considered a normal finding. In clients with chronic obstructive pulmonary
disease (COPD), airflow out of the lungs is impeded, trapping CO2 in the lungs.
➢ The body adjusts to the higher CO2 level (which would cause an increase in respirations in a non-COPD client) and then
uses the PaO2 as the drive for breathing.
➢ (Option 3) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation.
➢ To be therapeutic and prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's INR is
therapeutic for the diagnosis of atrial fibrillation.
➢ Educational objective:
Blood loss is a common complication of a total knee replacement. Monitoring the client postoperatively for signs of
blood loss and active bleeding is a priority.
51. The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question
is most important for the nurse to ask?
o "Have the assistive devices helped with dressing and grooming?" [5%]
o "How do you feel about the changes in your appearance?" [4%]
o "How is your pain control with the current medication regimen?" [59%]
o "Is your level of energy adequate for completing your daily activities?" [30%]
➢ Rheumatoid arthritis is an autoimmune disorder that affects joints and other
body systems.
➢ Chronic inflammation of the synovial joints causes increasing pain and swelling
in the joints and eventual joint deformities with decreased or absent range of
motion and loss of function.
➢ Clients become easily fatigued and must learn to pace themselves and use
assistive devices to accomplish activities of daily living.
➢ Goals of treatment are to manage pain, minimize loss of joint mobility,
maximize self-care, and maintain self-esteem and a positive body image. Assessing for adequate pain control is the
priority, as inadequate pain control will cause disuse of joints, leading to stiffness and decreased joint mobility (Option
3).
➢ (Options 1, 2, and 4) If pain is not adequately controlled, the client will be unlikely to use assistive devices and be too
fatigued to perform activities of daily living. This can lead to being dependent on others, causing frustration and poor
self-esteem and body image.
➢ Educational objective:
Pain control is the priority assessment for clients with rheumatoid arthritis. Without adequate pain control, clients will
have decreased ability to self-manage activities of daily living, maintain mobility and activity tolerance, and maintain
self-esteem and a positive body image.