1. All forms of muscular dystrophies have what element in common?

a. The average life expectancy is into the fourth decade

b. Cognitive development and functioning are not at a full level
c. Muscle membranes have a protein deficiency or absence of dystrophin
d. The cause is death is due to systemic infection

RATIONALE: Muscle dystrophies - set of genetic myopathies involved that are caused
by protein deficiency in the muscle membrane. Biologically, a person's DNA is not
producing a particular protein - dystrophin - required by muscle membranes to function
properly.
D. Cardiomyopathy leads to heart failure which is the cause of death of patients with
muscular dystrophy or respiratory failure.

2. A 75-year-old male with long-term alcohol abuse would likely experience which of the
following myopathies?
a. Polymyositis
b. Inclusion body myositis
c. Hypokalemic
d. Steroid-induced

RATIONALE: Long-term diuretic use. Other causes of hypokalemic myopathy-

potassium deficiency, excessive alcohol consumption, aldosteronism, intestinal wasting
of potassium (malabsorption or intoxication)

3. The diagnosis of fibromyalgia is based on the patient’s report of:

a. Subjective symptoms
b. Treatment for depression
c. Familial tendency of the condition
d. Long-term arthritis history

RATIONALE: Based on subjective symptoms as well as medical and surgical history.

Patients with fibromyalgia DO NOT have any associated musculoskeletal disorders,
therefore arthritis and bursitis should be ruled out.

4. A nurse is reviewing home care with a patient following a hip-replacement procedure.

Which of the following instructions would be included?
a. Exercise the affected extremity by turning the leg inward 5-10 times
b. Slightly bend the operative leg when getting up from the chair or bed
c. Progressively increase the amount of bedding at the waist daily
d. Use an elevated toilet seat in the main bathroom at home

RATIONALE: Include precautions to avoid abduction, flexion, or any movement which

may dislocate the hip prosthesis. This would include elevated toilet seat, hip abductor
pillow while in bed and instruct patient not to bend the hip greater than 90 degrees, don’t
 sit in a low chair, don't twist the body towards the operative side, don't turn leg inward
and keep the operative leg straight.

5. The nurse strongly suspects the occurrence of compartment syndrome in a patient

wearing a long-leg cast. In preparation for the physician to come and perform the
necessary treatment; the nurse would gather what supplies or equipment?
a. Syringe, needle and topical anesthetic to aspirate the hematoma
b. Ace bandages to wrap around the bivalved cast
c. A percussion hammer to physically assess reflexes for damage
d. Extra pillows to elevate the casted leg above the heart

RATIONALE: Treatment of compartment syndrome requires release of restriction to

accommodate swelling. If cast is causing restriction, it should be bivalved or cut down
both sides with ace wraps to hold in place. If fascia level, the patient will require surgery.
If CS is present, notify the physician immediately to prevent permanent disability or
losing the limb. If CS is present at extremity, extremity should not be elevated, should be
maintained at the level of the heart to maintain perfusion. Compartment syndrome
occurs when pressure rises in and around muscles. The pressure is painful and can be
dangerous. Compartment syndrome can limit the flow of blood, oxygen and nutrients to
muscles and nerves.

6. Of the following assistive devices, which would be the most appropriate for a patient who
has undergone a total hip replacement procedure for home use?
a. Heel lift boot
b. A “Reacher” tool
c. Continuous passive motion machine
d. Wheelchair

RATIONALE: It is important not to bend over or flex the extremity - for picking up things
A. prevent pressure ulcers in an immobilized patient
C. following a total knee replacement
D.use walking or cane to prevent prolonged sitting

7. A nurse is serving as a perception for a new graduate on an orthopedic unt. As they

enter a patient’s room using patient controlled analgesia (PCA), the nurse states, “this
pump is delivering a 2 mg basal rate of Morphine Sulfate, along with prn doses.” The
new graduate reflects understanding of the order through which statement?
a. “The maximum amount of Morphine to be received is 2mg per hour.”
b. “The pump administers a beginning dose of 2 mg and increases the amount
hourly.”
c. “Every hour, 2mg of Morphine is delivered continuously.”
d. “The patient receives 2 mg of the drug when he pushes the delivery button.”
 RATIONALE: PCA or round the clock pain medication is often utilized in the early
post-op period. PCA can be set to deliver a constant or basal rate in addition to the pt
being able to self administer a pore-set dose at prescribed intervals to achieve pain
control.

8. Which of the following should the nurse include when planning the care of a patient with
rheumatoid arthritis?
a. Maximize activities of daily living
b. Prevent deformities
c. Increase activity
d. Restrict calories

RATIONALE: During the planning stage, preventing contractures and deformities. Also, it
is important to provide health teachings. Rheumatoid arthritis (RA) is a chronic,
progressive, and disabling autoimmune disease. It causes inflammation, swelling, and
pain in and around the joints and can affect other body organs. RA usually affects the
hands and feet first, but it can occur in any joint

9. A patient is diagnosed with gout. The nurse should instruct this patient to avoid which of
the following foods?
a. Broccoli
b. Chicken
c. Lettuce
d. Gravies

RATIONALE: Low-purine, low calorie diet, and avoid alcohol and smoking. A patient
with gout should avoid foods high in PURINES. These include most red meats, organ
meats (liver, kidneys, sweetbreads), alcohol (especially beer).

10. A patient is admitted with muscle weakness and a blue-tinted rash on his face, neck, and
back. The nurse realizes this patient is most likely experiencing:
a. Myositis
b. Inclusion body myositis
c. Dermatomyositis
d. Polymyositis

RATIONALE:
A. Myositis may be triggered by an injury infection or autoimmune disease
D. Polymyositis consists of muscle weakness. Dermatomyositis has the same symptoms
as Polymyositis EXCEPT for a distinctive rash over the face, shoulders, arms and bony
prominence (blue-tinted rash sa eyelids, bridge of the nose, neck, elbows, knuckles, and
upper chest).

11. The most common tests used to confirm musculoskeletal disorders are:
 a. X-rays
b. Magnetic resonance imaging (MRI) scans
c. Computed tomography (CT) scans
d. Bone scans

RATIONALE: D. Bone scans are used for more detailed assessment. BUT usually,
always begin with the simplest diagnostic tool in confirming musculoskeletal disorders.

12. The physician orders an erythrocyte sedimentation rate (ESR) test for a client admitted
with severe pain, swelling, and redness in her joints. This test will help the physician to
diagnose which of the following disorders?
a. Lyme disease
b. Osteomalacia
c. SLE
d. Osteoporosis

RATIONALE: The purpose of an ESR test is to determine the presence of inflammation

so it is useful to disease or conditions with great deal of inflammation like RA or SLE.
The ESR test measures the rate at which the red blood cells (RBCs), or erythrocytes, in
a sample of whole blood, fall to the bottom of the Westergren tube. This process of
"falling" is called sedimentation.

13. A client is admitted after an automobile accident, and the X-ray shows she has a
comminuted fracture of the right tibia. Which of the following describes a comminuted
fracture?
a. It is a fracture in which parts of the bone are broken into small pieces.
b. The fracture has not caused skin to be disrupted.
c. It occurs when the broken sections of the bone are not in alignment with one
another.
d. The break did not go completely through the bone

RATIONALE:
Incomplete or partial fracture – This is
a crack that does not completely break
the bone into two or more pieces.
Complete fracture – This is a fracture in
which the bone is completely broken
into separate pieces.
Closed fracture - If the injury doesn't
break open the skin.
Open fracture or compound fracture - If
the skin does open.
14. When caring for a client with a bone disorder, the nursing priority must be:
a. Alleviation of pain and stress
b. Maintenance of correct body alignment and management of pain
c. Pain relief and preservation of joint mobility.
d. Decreasing pain and immobilizing the affected joint

RATIONALE: PRIORITY

15. Ankylosing spondylitis can be best be described as:

a. A musculoskeletal disorder that is caused by the bite of deer tick.
b. An inflammatory disorder that causes uric acid crystals to form in a joint.
c. A forward rounding of the thoracic spine.
d. A type of arthritis that causes the spine to stiffen and possibly fuse.

RATIONALE: is a type of arthritis that primarily affects the spine. It is an inflammatory

disorder that causes the spine to stiffen and possibly fuse. NO KNOWN CAUSE. More
common in men, usually begins in early adulthood. Symptoms - back pain accompanied
by loss of mobility in the spine, p[ain worse at night and may happen in the hips and
legs.
A. Lyme disease
B. Gout
C. Kyphosis

16. Which of the following clients would be most at risk for scoliosis?
a. A 45-year-old woman
b. A 23-year-old male
c. An 80-year-old male
d. A preteen girl whose mother had scoliosis

RATIONALE: Scoliosis is NOT usually diagnosed in older adults. More likely to occur in
girls (teenagers). Has a genetic component. Scoliosis is a sideways curvature of the
spine that most often is diagnosed in adolescents.There is no cure for scoliosis, but the
symptoms can be reduced.

17. The primary care provider determines that a 55-year-old female client is experiencing
menopause and is also at risk for osteoporosis. What foods other than milk can the
nurse suggest to this client to increase her calcium intake?
a. Seafood, wheat, corn, green vegetables
b. Chicken, green vegetables, sardines, broccoli
c. Green vegetables, sardines, salmon with the bone, broccoli
d. Eggs, cheese, sardines, fish
 RATIONALE:
Proteins: Chicken and eggs
Carbohydrates: Wheat and corn
OTHER FOODS HIGH IN CALCIUM:
● Dairy products, such as cheese, milk and yogurt
● Dark green leafy vegetables, such as broccoli and kale
● Fish with edible soft bones, such as sardines and canned salmon
● Calcium-fortified foods and beverages, such as soy products, cereal and fruit juices,
and milk substitute

18. What risk factors identified by the nurse would put a client at risk for developing
osteoporosis?
a. Menopause, stress, sedentary lifestyle, smoking, excessive alchohol
intake, and diet deficient in calcium and vitamin D
b. Family history, age, history of falls, smoking, alcohol, and diet deficient in
protein
c. Diet deficient in protein and carbohydrates, smoking, excessive alcohol intake,
stress, and sedentary lifestyle
d. Inadequate sunlight exposure, obesity, depression, poor dietary intake of
calcium, and excessive alcohol intake

RATIONALE: Others DO NOT contribute to the development of osteoporosis

19. Alendronate (Fosamax) is ordered for a client with osteoporosis. Which information
should the nurse include in teaching the client about this drug?
a. It is a selective estrogen receptor modulator.
b. It increases bone mass.
c. It may be obtained as a nasal spray.
d. It prevents bone resorption and is taken orally.

RATIONALE: It belongs to a class of medications called bisphosphonates. Fosamax

works to decrease bone breakdown in the body and make bones stronger. Fosamax
comes as 70-milligram (mg) tablets that are taken by mouth, typically once a week.
BC. Calcitonin or miacalcin increases bone mass and is dispensed as nasal spray.
A. Evista (Raloxifene) - is a medication used to prevent and treat osteoporosis in
postmenopausal women and those on glucocorticoids

20. The nurse is preparing a client who sustained a hip fracture for discharge. The nurse
should teach the client to avoid which of the following groups of activities to prevent
dislocation of the hip?
a. All exercises, bedrest, and using raised toilet seats
b. Using reachers for applying shoes and socks, and sitting in chairs with arms
c. Taking leisurely walks, low chair seats, and bending at hips
d. Crossing legs, bending at hips, and sitting on low toilet seats
 RATIONALE: The client with hip surgery should avoid all activities that will cause hip
adduction, internal rotation, flexion. The focus of teaching is to avoid dislocation and risk
for further injury.

21. Mrs. Montes, a client with a total hip replacement, is concerned about dislocation of the
prosthesis. What can the nurse say to reassure this client?
a. “Perform bending exercises as often as able to prevent dislocation.”
b. “Use of elevated toilet seats alone will prevent dislocation.”
c. “Remove the foam abduction pillow as soon as possible to prevent dislocation.”
d. “Avoiding activities that cause adduction of the hip to prevent dislocation.”

RATIONALE: Extremities of internal rotation, adduction @ 90-degrees flexion of the hips

should be avoided for 4-6 weeks after surgery to prevent dislocation.
A. bending activities may place clients at risk for dislocation
B. it alone does not suffice to prevent dislocation
C. abduction pillows are used to prevent external rotation and MUST be used post-op.

22. A client has undergone a lumbar laminectomy and has just returned to the nursing unit.
It is essential for the nurse to perform which of the following activities during this period?
a. Early ambulation
b. Vital signs checks every half-hour
c. Neurovascular checks
d. Assessment of bladder function

RATIONALE: Musculoskeletal injuries and subsequent treatment have the potential to

cause complications. bleeding and swelling from surgery- may cause compression of
nerves that can lead to permanent neurological damage and paralysis. Frequent
assessment NVS of the client is essential after laminectomy.
6 P’s-pain, poikilothermia, pallor, paresthesia, pulselessness and paralysis
B. not necessary unless sa PACU
D. can be residual effect of anesthesia

23. A client in traction slides down in the bed so that the feet touch the foot of the bed. What
should the nurse do to ensure that the pull of traction remains uninterrupted?
a. Release the weights, pull the client up in bed, then reapply weights
b. Ask the physician for a change in the amount of weight ordered
c. Move the client up in bed without releasing the pull of traction on the
extremity
d. Elevate the client’s feet on a pillow

RATIONALE: Pull of traction on the affected limb should never be disturbed to ensure
healing and union of the bone in proper alignment.
A. Change in weight is not indicated
B. This is INDEPENDENT Nursing Activity.
 D. will not correct the situation

24.Nurse Vanessa is caring for a client with skeletal traction. It is most important that she
monitor which of the following?
a. The pin site for unusual redness, swelling, purulent
drainage, and foul odor.
b. The distance between the client’s hop and the traction.
c. The number of times the client exercises the affected limb.
d. How the client is coping with immobilization.

RATIONALE: the major complication of skeletal traction is infection. The nurse must
provide pin site care using aseptic technique to prevent infection.
BCD. might be appropriate, but A is an essential nursing intervention

25.A client in skeletal traction complains of unrelieved pain at rest and paresthesia in the
affected extremity. The assessment by the nurse reveals diminished pulse, pallor, and
increases pain on passive motion. What must the nurse do first?
a. Administer oxygen
b. Encourage deep-breathing and coughing exercises
c. Administer pain medication as ordered
d. Notify the physician immediately.

RATIONALE: unrelieved pain, diminished pulses, pallor, and increased pain on passive
motion are all symptoms of compartment syndrome. Medical Emergency because of the
pressure - must relieve pressure in the affected limb.otherwise, swelling will lead to
permanent complications
A. Inappropriate initial action for this situation
BC. Appropriate, but NOT priority for this situation

26. The nurse is caring for a client who had open reduction and internal fixation (ORIF) of
the right femur 4 days ago. The client complains of intense pain, swelling, tenderness
and warmth at the site, chills, malaise, and has a temperature of 102.2°F (39°C). This
data indicates which of the following?
a. Fat embolism
b. Compartment syndrome
c. Osteomyelitis
d. Malunion of the bone

RATIONALE: Clinical manifestation of Osteomyelitis.

A Acute.Respiratory distress
B. progressively worsening pain distal to the site, unrelieved by analgesics
D. will NOT cause elevated temperature.

27. A client presents to the Emergency Department with a shoulder injury sustained while
playing basketball. The nurse teaches the client about which of the following diagnostic
 tests that would best identify abnormalities of the cartilage and soft tissue surrounding
the joint
a. Standard x-ray
b. Magnetic resonance imaging
c. Bone scan
d. Arthroscopy

RATIONALE: A. Will NOT provide details that are necessary to evaluate soft tissue.
C. malignancies

28. A client to the Emergency Department with multiple injuries caused by a motor vehicle
accident. The nurse suspects that the client may have a right fractured hip after noting
which of the following distinctive signs?
a. The client reports increased pain with movement of the limb.
b. There is bruising over the right hip.
c. The right leg is shorter than the left.
d. The right leg is shorter than the left

RATIONALE: The fractured extremity will be shorter than the unaffected one because of
contraction of the muscle, swelling at the site, and misalignment of the bone fragments
AB. are not caused solely by hip fracture, NOT Distinctive signs

29. The nurse is providing care for a young athlete who presents with a muscle strain of the
back that occurred during a tennis match. Client teaching about preventing such injuries
in the future should include which of the following
a. Drink 2 liters of Gatorade before every sports activity
b. Routine stretching and warm-up exercises before every sports activity
c. Wearing a back support brace
d. Drinking a high-protein shake before activity

RATIONALE: Essential before strenuous activities to prepare the muscles to withstand

the stress of the motion.
A.D. DO NOT prevent strains from happening

30. The nurse provides care to an elderly client in Russell’s skin traction prior to reduction of
a left hip fracture. Priority nursing assessment should include observation of which of the
following?
a. The pin sites for infection
b. The client’s skin for
breakdown
c. The left leg for
decreasing length
d. The client's skin for
dehydration
 RATIONALE: Russell’s traction can partially immobilize the extremity to reduce spasms.
Important for the nurse to monitor skin under the traction for breakdown, especially over
bony prominences and other pressure areas
A. no insertion sites
D. not necessarily done under the skin traction rather, it can be done in other areas.

31. A client presents to the clinic with Paget’s disease. The client’s chief complaint is skeletal
pain. The nurse interprets this symptom as which of the following?
a. A characteristic of the disease process
b. An ominous sign that should be reported to the physician immediately
c. Caused by bony deformities
d. Caused by poor calcium uptake by the bones

RATIONALE: Paget disease is a localized disorder of bone remodeling that typically

begins with excessive bone resorption followed by an increase in bone formation. This
osteoclastic overactivity followed by compensatory osteoblastic activity leads to a
structurally disorganized mosaic of bone (woven bone), which is mechanically weaker,
larger, less compact, more vascular, and more susceptible to fracture than normal adult
lamellar bone.

32. The nurse teaches the client with osteoarthritis about managing joint stiffness associated
with the disease. The nurse knows that the teaching objective has been met when the
client makes which of the following statements?
a. “I will balance activities with with rest periods throughout the day”
b. “I will increase my calorie intake to supplement my energy needs”
c. “I will apply a heating pad to the affected site when I feel pain”
d. “I will apply a cold pack to the affected site when I feel pain”

RATIONALE: Joint pain with movement, like osteoarthritis, is aggravated by continual

activity. Planned rest period is important for managing discomfort. Clients with
osteoarthritis should maintain regular exercise program to maintain joint flexibility and
mobility.
B. Do not address management of joint stiffness
CD. For temporary relief only

33. The nurse provides teaching to a 35-year old client who is a construction worker about
managing symptoms associated with chronic low back pain. The nurse determines that
the teaching objective was met when the client makes which of the following
statements?
a. “I will wear a brace at work”
b. “I plan to start a regular exercise program”
c. “I will not carry objects more than 10 pounds”
d. “I will try to exercise whenever I can”
 RATIONALE: Strengthening the back and abdominal muscle to prevent injuries. Goal of
managing back paint is to prevent recurrence. Back brace and sporadic exercise-NOT
appropriate

34. A client had above-the-knee amputation yesterday because of advanced peripheral

vascular disease. The client is complaining of pain and itching in the amputated limb.
The nurse should take which of the following actions?
a. Administer the prescribed analgesic for pain and explain to the client that
this sensation is typical.
b. Explain to the client that the limb is no longer present and the sensation will go
away.
c. Notify the physician immediately since this could be a sign of fat embolism.
d. Obtain a psychiatric assessment for the client who may be hallucinating

RATIONALE: Normal to continue to have sensation in the amputated limb sites since
nerve endings are still present. The client feels real pain and the intervention is provided
to relieve it.

35. The nurse assesses a client with osteoarthritis notes finger deformities on the proximal
and distal interphalangeal joints. The nurse documents this common finding as which of
the following in this medical record?
a. Interphalangeal drift and ulnar deviation
b. Boutonniere deformity
c. Heberden’s and Bouchard nodes
d. Swan neck deformity

RATIONALE: Heberden's nodes are small bony growths that appear at the finger joint
closest to the tip of your finger. Bouchard's nodes, a similar symptom, appear at the
finger's middle joint. These nodes are symptoms of osteoarthritis of the hands.

36. A nurse is caring for a child who has just received a cast. Which of the following
considerations would be important in providing care for this child?
a. Give the child a blunt object to help with the itching under the cast
b. When handling the cast in the first 24 hours, use fingertips only.
c. Assess the casted extremity every 15-30 mins the first two hours after cast
application.
d. Apply powder to the inside edges of the cast to help decrease moisture

RATIONALE: For intact circulation, sensation and movement

A. NO object inside the cast
B. NOT to use fingertips for the first 48 hours - this can cause dent and pressure in the
extremity. NO lotion - causes skin irritation
37. During discharge preparations, a patient with osteoporosis makes all these statements.
Which statement indicated to you that the patient needs additional teaching?
a. “I take my ibuprofen every morning as soon as I get up”
b. “My daughter removed all of the throw rugs in my home”
c. “My husband helps me every afternoon with range-of-motion exercises”
d. “I rest in my recliner chair everyday for at least an hour”

RATIONALE: Ibuprofen can cause abdominal discomfort or pain and GI ulceration, it

should be given with meals.

38. The patient suffered a fractured femur. Which of the following would you tell the nursing
assistant to report immediately?
a. The patient complains of pain
b. The patient appears confused
c. The patient’s blood pressure is 136/38
d. The patient voided using the bedpan

RATIONALE: Fat embolism- confusion = serious complication. It is a fracture of long

bones.Earliest manifestation is altered mental status caused by low arterial O2 level.

39. A change of shift report. Which patient should the nurse assess first?
a. 42-year-old patient with carpal tunnel syndrome complaining of pain
b. A 64-year-old patient with osteoporosis who is waiting for discharge
c. A 28-year-old patient with fracture complaining that the cast is tight
d. A 56-year-old patient with left leg amputation complaining of phantom pain

RATIONALE: At risk for circular impairment and peripheral nerve damage

ABD. NOT urgent compared to C

40. A cold treatment, specifically an ice massage, has been ordered for 20 minutes for a
patient’s complaint of chronic pain. Which of the following observations would indicate a
complication of tissue intolerance?
a. Redness or inflammation
b. Mottling or graying
c. Burning or tingling
d. Numbness or cold

RATIONALE: during procedure, observe site every 5 mins for signs of tissue intolerance:
Blanching, Mottling or graying
A. inflammatory process
C. ischemia
D. decreased pain perception / nerve damage
41. An elderly patient, with mild osteoarthritis, needs instruction on exercising. In planning
nursing care, which instruction by the nurse would best help this patient?
a. Swimming is the only helpful exercise for osteoarthritis
b. Warm-up exercises should be done prior to exercising
c. Exercises should be done routinely even if joint pain occurs
d. Isometric exercises are most helpful to prevent contractures

RATIONALE: Stretching at the beginning and end of exercise

C. Painful joints should not be exercised
D. DO NOT involve joint movement

42. You are caring for a client with fibromyalgia. Which of the following would be a priority
nursing intervention for this client?
a. Stress the importance of having regular eye examinations
b. Advise the client to limit the time spent in direct sunlight
c. Check neurovascular status every 4 hours.
d. Focus on pain management and stress reduction

RATIONALE: a condition that causes pain all over the body (also referred to as
widespread pain), sleep problems, fatigue, and often emotional and mental distress.
People with fibromyalgia may be more sensitive to pain than people without fibromyalgia.

43. A truck driver presents to the primary care provider with complaints of persistent back
pain. The nurse explains that which client activity documented during the nursing history
may contribute to further back injury?
a. Prolonged standing or sitting
b. Providing back support with a pillow when sitting
c. Lifting objects close to the body
d. Shifting positions often when sitting for prolonged periods

RATIONALE: because of the additional stress placed on the structure supporting the
back.
BCD. Appropriate actions

44. A client has undergone a lumbar laminectomy. Which of the following nursing
interventions would be best 4 hours postoperatively?
a. Have the client lying in bed in good alignment with the head flat.
b. Sit the client at the site of the bed.
c. Have the client use the bed rail for support when getting out of the bed.
d. Have the client sit in a chair to watch TV.

RATIONALE: Client is logrolled and the vertebral column is aligned at all times with the
head of bed flat in position.
C. shifts the vertebral column
45. The nurse provides teaching to a 50-year-old male Caucasian client with low back pain.
The client weighs 200 pounds, drives a forklift, sits for prolonged periods, and seldom
participates in exercise activity. What risk factors should the nurse include in the
discussion?
a. Age, obesity, lack of exercise, genetic factors
b. Degenerative disc disease, gender, race
c. Lack of exercise, obesity, sitting for prolonged periods.
d. Degenerative disc disease, race, inactivity

RATIONALE: others NOT associated.

46. The nurse is caring for a client with low back pain. The client states that the job requires
long hours of sitting and that the doctor suggested a new job. The client is supporting a
family and cannot afford to change jobs at this time. The nurse initiates a teaching plan,
which includes guidance to:
a. Increase fluids
b. Lose weight
c. Modify the work environment to decrease back stress.
d. Take NSAIDS during the day to decrease pain level

RATIONALE: D. nurse DO NOT prescribe meds B. not indicated ang weight increasing
fluids not associated with back pain

47. The nurse is evaluating a client who is being treated for low back pain. The nurse
concludes that goals have been met when the client does which of the following?
a. Walks in a stiff, flexed gait
b. Shows tenderness when the muscle close to the affected disc is palpated
c. Bends at the waist
d. Experiences stronger sensations in the affected limb

RATIONALE: A. Not a positive sign

B. sx of a problem
D. should be equal on both sides

48. The client with low back pain from a muscle strain asks the nurse if diagnostic testing will
include an MRI. The nurse’s best response includes which of the following?
a. Conservative treatment for 4 weeks will precede diagnostic testing
b. The doctor will order a CT scan
c. The doctor will order a blood work
d. An MRI is likely

RATIONALE: Conservative treatment - NSAIDS, rest, Physical Therapy for 4 weeks, if

no improvement, doctor will order CT scan or MRI.
49. The nurse provides care for a client who was placed in a halo brace within the last 24
hours because of a spinal cord injury. Which of the following is the first priority of the
nurse?
a. Encourage active range of motion to lower extremities
b. Ask how the client is able to reposition in bed
c. Loose connections on the vest to observe the skin
d. Examine the pin sites

RATIONALE: for redness, swelling. Halo brace should not be moved.

50. The nurse will be caring for a client with a spinal cord injury who has been placed in
crutchfield tongs. The nurse plans which of the following interventions for the client?
a. Leaving the assessment of the weights to the physician
b. Using a stryker frame bed
c. Calling the physician to determine if the traction is appropriate
d. Removing the weights during repositioning

RATIONALE:

51. The family members of a client with a spinal cord injury tell the nurse that the client
becomes angry whenever someone tries to help or participate in care. The nurse’s best
response is to:
a. Assist the family to understand the source of the client’s anger
b. Ask the family to refrain from giving care
c. Tell that client that the family will not visit anymore
d. Ask the client to stop acting out with the family.

RATIONALE: Help understand the client’s anger.Then the family would make the choice
of whether or not to continue in the care.
C. threatening and inappropriate

52. A nurse is conducting teaching for a client with a spinal cord injury who is being
discharged with halo traction. The nurse concludes that further instruction is necessary
upon learning that the client intends to:
a. Monitor balance carefully
b. Care for the skin under the vest daily.
c. Drive in the daytime only
d. Drink with a straw

RATIONALE:The client cannot drive because the traction limits mobility and impairs
range of vision.
D. Drink and cut foods into small pieces to facilitate chewing.
53. The nurse is caring for a client with a spinal cord injury who has very little interest in
eating or drinking. The nurse plans to instruct the client about risks associated with
inadequate intake of food and fluids including which of the following
a. Contractures of the legs
b. Skin breakdown
c. Headaches
d. Diarrhea

RATIONALE: which then results in infection.

D. usually constipation associated with dec. fluid intake.

54. A client with a musculoskeletal disorder needs PRN pain medication.

Which of the following questions would be most helpful in assessing this need?
a. “When did you last receive your pain medication?”
b. “Is the pain burning, throbbing, or knifelike?”
c. “Do you want an oral or injectable pain medication?”
d. “Tell me what the pain feels like?”

RATIONALE: An open-ended question will allow to describe the pain in his own terms.
ABC. NOT open-ended questions.

55. In planning discharge teaching for a postoperative client after lumbar surgery, the nurse
would instruct the client to exercise regularly to strengthen which muscles?
a. Buttock
b. Abdominal
c. Trapezius
d. Rectus Femoris

RATIONALE: Strengthening the abdominal muscles adds support to the muscles

supporting the lumbar spine.
ACD. DO NOT contribute significantly.

56.When assessing a client for carpal tunnel syndrome, the nurse would
a. Ask the client to hold their wrist in an acute flexion for 60 seconds.
b. Ask the client to bend the knee up to their chest.
c. Ask the client to bend their arm out to the side.
d. ask the client to lie on their abdomen and lift their arms up one at a time.
RATIONALE: Defined as the Phalen’s test- Positive(+) if patient complains numbness
and burning sensation on fingers during the test.
BCD. Bursitis- inflammation of a bursa. A bursa is a closed, fluid-filled sac that works as
a cushion and gliding surface to reduce friction between tissues of the body. The major
bursae (this is the plural of bursa) are located next to the tendons near the large joints,
such as in the shoulders, elbows, hips, and knees.
57. What objective data would the nurse anticipate finding when assessing a client with
chronic gout?
a. Swarm-neck deformities
b. Pain and tenderness over the biceps
c. Swollen finger joints with a white chalky discharge
d. Pain and locking when extending the knee
RATIONALE: Gout - Heterogeneous group conditions related to genetic defect of purine
metabolism resulting in hyperuricemia. Sodium urate crystals called tophi are
accumulated and deposited in the peripheral areas of the body (e.g. toes, hands).
A. Chronic rheumatoid arthritis.
B. Tendonitis
D. Injury sa meniscus.

58.The client rates his present pain level at 9 on a scale of 1-10. An appropriate goal or
outcome for a patient with a diagnosis of “acute pain r/t musculoskeletal disorder” would
be?
a. The client will report a decreased pain level
b. The client will not have any additional swelling or rash in extremities
c. The nurse will administer pain medication PRN as requested by the client to control pain.
d. The client will rate his pain as a 4 on a scale of 1-10
RATIONALE: patient-centered, realistic and measurable.
A. NOT measurable
B. nothing to do with the client’s pain
C. NOT client-centered

59. A nurse is performing pin site care on a client in skeletal traction. Which finding would
the nurse expect to note when assessing the pin sites?
a. Loose pin sites
b. Clear drainage from the pin sites
c. Purulent drainage from the pin sites
d. Redness and swelling around the pin sites
RATIONALE: CD. Sign of infection. A. inform the physician.

60. A nurse is caring for a client who has been placed in Buck’s extension traction while
awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete
neurovascular assessment of the affected extremity and plans to assess:
a. Vital signs and bilateral lung sounds
b. Warmth of the skin and the temperature in the affected extremity
c. Pain level and for the presence of edema in the affected extremity
d. Color, temperature, movement, capillary refill, and pulse of the affected extremity
RATIONALE:

61. A client in the emergency department has a castapplied. The client arrives at the nursing
unit, and the nurse prepares to transfer the client into the bed by:
a. Placing ice on top of the cast
b. Supporting the cast with the fingertips only
c. Asking the client to support the cast during transfer
d. Using the palms of the hands and soft pillows to support the cast

RATIONALE: Use of palms to prevent indentations. Using soft pillows to support the
curves of the cast to prevent flattening of the cast to the weight of the body.
A. Ice may be mixed with the cast to prevent swelling, BUT should be performed after.
B. Fingertips cause dents and pressure.
C. Asking the client is inappropriate

62. A nurse is caring for a client who has been placed in Buck’s extension traction. The
nurse provides for countertraction to reduce shear and friction by:
a. Using a footboard
b. Providing an overhead trapeze
c. Slightly elevating the foot of the bed
d. Slightly elevating the head of the bed

RATIONALE: The part of the bed under an area of traction is usually elevated to aid in
countertraction. Foot of the bed is elevated for Bucks traction, NOT the head of the bed.
A. NOT used to provide Countertraction

63. The nurse is caring for a client who develops compartment syndrome from a severely
fractured arm. The client asks the nurse how this can happen. The nurse’s response is
based on the understanding that:
a. A bone fragment has injured the nerve supply in the area
b. An injured artery causes impaired arterial perfusion through the compartment
c. Bleeding and swelling cause increased pressure in an area that cannot expand
d. The fascia expands with injury, causing pressure on underlying nerves and muscles

RATIONALE: Bleeding and swelling puts pressure on the nerves, muscles and blood
vessels in the compartment triggering symptoms.

64. A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse
prepares to provide which type of wound care to the fasciotomy site?
a. Dry sterile dressings
b. Hydrocolloid dressings
c. Wet sterile saline dressings
d. One-half strength betadine dressings

RATIONALE: Fasciotomy site is not sutured, but is left opened to relieve pressure and
edema. The site is covered with Wet sterile saline dressings. After 3-5 days, when
perfusion is adequate and edema subsides, the wound is debrided and closed. B. NOT
 used in open cleas incisions. D. since clean, no need of betadine, which can irritate
normal tissues.

65. An older client admitted to the hospital with a hip fracture is placed in Buck’s extension
traction. The nurse plans to frequently monitor which specimen item?
a. Temperature
b. Mental state
c. Neurovascular status
d. Range of motion ability

RATIONALE: NVS must be assessed frequently. Older clients are at risk of

neurovascular compromise because they already have disorders that affect the
peripheral vascular system

66. Buck’s extension traction is applied to an older client following a hip fracture. The nurse
explains to the client that this type of traction is:
a. Traction involving the use of cast
b. Skeletal traction involving the use if surgically inserted pins
c. Circumferential traction involving the use of a belt around the body
d. Skin traction involving the use of traction attached to the skin and soft tissues

RATIONALE: to decrease painful muscle spasm that accompany fractures. The weight
that is being used is limited (5-10 lbs) to prevent injury to the skin.

67. A client has Buck’s extension traction applied to the right leg. The nurse plans which of
the following interventions to prevent complications from the device?
a. Provide pin care once a shift
b. Massage the skin of the right leg with lotion every 8 hours
c. Inspect the skin on the right leg at least once every 8 hours
d. Release the weights on the right leg for range of motion exercises daily

RATIONALE: to prevent irritation or inflammation.

A. NO PINS in skin traction
B. Not indicated or inappropriate in this case.
D. Never releases the weights unless ordered by the physician

68. The nurse is caring for a client with a newly applied leg cast. The nurse prevents the
development of compartment syndrome by:
a. Elevating the limb and applying ice to the affected leg
b. Elevating the limb and covering the limb with bath blankets
c. Keeping the leg horizontal and applying ice to the affected leg
d. Placing the leg in a slight dependent position and applying ice

RATIONALE: by controlling edema- this is achieved optimally with elevation and ice.
69. A client has sustained a closed fracture and has just had a cast applied to the affected
arm. The client is complaining of intense pain. The nurse has elevated the limb, applied
an ice bag, and administered an analgesic, which has provided very little pain relief. The
nurse interprets that this pain may be caused by:
a. Infection under the cast
b. The anxiety of the client
c. Immpaired tissue perfusion
d. The newness of the fracture

RATIONALE: Most pain associated with fractures can be minimized with rest, elevation
and application of cold and analgesics. Pain that is not relieved by these measures
should be reported to the physician because this may be caused by impaired tissue
perfusion, tissue breakdown or even tissue death or necrosis.
A. Since it's a new closed fracture and cast, infection would not have had time to set
in yet.

70. The client with a fractured femur experiences sudden dyspnea. A set or arterial gasses
reveal the following: pH is 7.32 PaCO2 is 43, PaO2 is 58, and HCO3 is 20. Which of the
following components of the ABG results supports the nurse’s suspicion of fat embolus?
a. pH
b. paO2
c. HCO3
d. PaCO2

RATIONALE: Refer to normal values. Hypoxemia- Other features that distinguish fat
embolism from pulmonary embolism include elevated temperature and the presence of
fat in the blood with fat embolism.

71. Which statement would reassure the nurse that the parents understand the teaching
regarding their 4-year-old with genu valgum?
a. “This deformity was caused by a vitamin D deficiency.”
b. “Casting will be needed to correct the deformity.”
c. “This is a normal developmental issue that will improve as the child
grows.”
d. “This deformity is a manifestation of Paget’s disease.”

RATIONALE: It is usually normal around 4-5 years old and will improve with time. Genu
valgum (knock-knees) is a common lower leg abnormality that is usually seen in the
toddler, preschool and early school age child. In genu valgum, the lower extremities turn
inward, causing the appearance of the knees to be touching while the ankles remain
apart.
72.The school nurse is screening the sixth-graders for scoliosis. She notes that one of the
students has excessive convex curvature of the cervical thoracic spine. This finding
would be indicative of:
a. Kyphosis
b. Torticollis
c. Lordosis
d. Scoliosis

RATIONALE: D. Lateral S-curve in the spine

C. Concave curvature of the lumbar spine (buntis)
B. tilt in the head by rotation of the cervical spine

73. A nurse is educating a family about the type of fracture their 8-year-old son has
experienced. Which of the following would be an accurate way to explain a closed
fracture of the radius to the family?
a. “One of the bones in the arm broke completely, but did not penetrate the
skin.”
b. “One of the bones in the arm is crushed and broken completely.”
c. “One of the bones in the arm broke completely and penetrated the skin.”
d. “One of the bones in the arm is broken incompletely, like a green twig.”

RATIONALE: Closed fracture - will NOT penetrate.

D. Greenstick fracture
B. Compression fracture

74. A nurse is evaluating a child for compartment syndrome after fracture reduction. Which
assessment finding would alert the nurse to the presence of this complication?
a. Pain, relieved by medication
b. Capillary refill under three seconds
c. Absence of space between cast and extremity
d. Pink extremities distal to cast

RATIONALE: Tight cast would indicate swelling with compartment syndrome.

ABD. NORMAL signs after a fracture reduction.

75. A school nurse is evaluating a child who hurt her leg in gym class. The nurse believes it
is a muscle strain, but is still going to refer her to her pediatric doctor. Which instruction
should the child follow until she is seen by the doctor?
a. Apply ice for 20 minutes at a time.
b. Increase motion to the extremity quickly to increase circulation
c. Go back to gym class and participate
d. Try to walk on it, even if she experiences pain.
 RATIONALE: Ice or ice packs will cause blood vessels to constrict and reduce blood
supply to the injury. Reducing blood flow to the area minimizes swelling after an injury.

76. A nurse is caring for a client with osteosarcoma. Which symptoms would the nurse
expect?
a. Difficulty using either hand
b. A stiff back
c. Swelling in the area of the clavicle
d. Pain in the femur especially on weight bearing

RATIONALE:
● Swelling near a bone
● Bone or joint pain
● Bone injury or bone break for no clear reason

77. When discussing home care for an infant who has developmental hip dysplasia, the
nurse understands that the Pavlik harness will need to be used for what length of time?
a. A month
b. More that six months
c. A few days
d. Three to four months

RATIONALE: When starting treatment, most doctors recommend that the baby wear the
harness or brace full-time for 6-12 weeks. Some doctors allow the Pavlik harness to be
removed for bathing and diaper changes as long as the legs are kept apart to keep the
hips pointed at the socket.

78. The nurse knows the parents need additional clarification about caring for a plaster cast
of an ankle fracture when which following statement was given?
a. “I will not allow him to swim until the cast is removed.”
b. “I will encourage him to not scratch underneath the cast.”
c. “I will use ice on the cast for the first 24 hours to reduce the swelling.”
d. “ I can let him walk around in a few hours since it will be dry enough to
walk on.”

RATIONALE: OTHERS are proper statements

79. The nurse understands that when caring for a child in skeletal traction, which action
should be avoided?
a. Keep the weights out of the reach of the child
b. Put the bed linens over the traction ropes and pulleys
c. Check to ensure that the child remains in proper body alignment
d. Ensure that weights are hanging freely
 RATIONALE:
● Ensure that the traction weight bag is hanging freely, the bag must not rest on the
bed or the floor.
● If the rope becomes frayed, replace them.
● The rope must be in the pulley tracks.
● Ensure the bandages are free from wrinkles.
● Tilt the bed to maintain counter traction.

80. When assessing capillary refill on the toe of a casted leg, the original color returned in 2
seconds. The nurse’s next action would be able to:
a. Immediately notify the physician.
b. Elevate the extremity on two pillows and recheck the capillary refill.
c. Prepare the child for immediate removal of the cast.
d. Document the findings.

RATIONALE: Normal findings.

81. The nurse recognizes that additional instruction is needed when the mother of an
adolescent with a MilWaukee brace says:
a. “I understand that she can wear it for a few hours and take it off when she
goes out to a party.”
b. “She will have to wear the brace for a few months and be reevaluated before she
can stop using it.”
c. “I will encourage her to wear a t-shirt under it to prevent
irritation to the skin.”
d. “I understand that I will need to check the skin underneath the
brace for any skin breakdown each day.”

RATIONALE: A Milwaukee brace is a body brace worn to minimize the

risk of progression of scoliosis and kyphosis. It is also known as a
cervical-thoracic-lumbo-sacral orthosis (CTLSO). It is worn over an
undershirt to protect the skin

82. A client is hospitalized for open reduction of a fractured femur. During postoperative
assessment, the nurse monitors for signs and symptoms of fat embolism, which include:
a. Pallor and coolness of the affected leg
b. Nausea and vomiting after eating
c. Hypothermia and bradycardia
d. Restlessness and petechiae

RATIONALE:
● rapid breathing.
● shortness of breath.
● mental confusion.
 ● lethargy.
● coma.
● pinpoint rash (called a petechial rash), often found on the chest, head, and neck
area, which occurs due to bleeding under the skin.
● fever.
● anemia.

83. A client is treated in the emergency department for a Colles’ fracture sustained during a
fall. What is a colles’ fracture?
a. Fracture of the distal radius
b. Fracture of the olecranon
c. Fracture of the humerus
d. Fracture of the carpal scaphoid

RATIONALE:
B. An olecranon fracture is a break in the “pointy bone” of your elbow that sticks out
when you bend your arm, which is actually the end of the ulna.
C. A humerus fracture refers to any break in this bone.
D. A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. This
type of fracture occurs most often after a fall onto an outstretched hand.

84. A client has sustained a right tibial fracture and has just had a cast applied. Which
instruction should the nurse provide in his cast care?
a. “Cover the cast with a blanket unti the cast dries.”
b. “Keep your right leg elevated above the heart level.”
c. “Use a knitting needle to scratch itches inside the cast.”
d. “A foul smell from the cast is normal.”

RATIONALE: OTHERS: inappropriate

85. A client has a herniated disk in the region of the third and fourth lumbar vertebrae. On
assessment, the nurse expects to note:
a. Hypoactive bowel sounds
b. Severe low back pain
c. Sensory deficits in one arm
d. Weakness and atrophy of the arm muscles

RATIONALE: If the herniated disc is not pressing on a nerve, the patient may experience
a low backache or no pain at all. If it is pressing on a nerve, there may be pain,
numbness or weakness in the area of the body to which the nerve travels. Typically, a
herniated disc is preceded by an episode of low back pain or a long history of
intermittent episodes of low back pain.
86. A client with possible osteoarthritis is having x-rays performed on both knees. X-rays of
an osteoarthritic joint reveal:
a. Enlargement of the joint space or margin
b. Fluid deposition in joint spaces
c. Osteophyte formation
d. Cartilage growths at weight-bearing joints

RATIONALE: Osteoarthritis results in characteristic X-ray appearances including joint

space narrowing, formation of osteophytes (bone spurs), articular surface cortical
irregularity and/or sclerosis, and formation of sub-cortical cysts (geodes).

87. Which is the most appropriate nursing diagnosis for a client with a strained ankle?
a. Impaired skin integrity
b. Impaired physical mobility
c. Risk for deficient fluid volume
d. Disturbed body image

RATIONALE: DO NOT walk on a sprained ankle. The inflamed tissue needs time to heal,
and walking on it too soon may cause more damage.

88. The physician diagnoses primary osteoporosis in a client who has lost bone mass. In
this metabolic disorder, the rate of bone disruption accelerated while bone formation
slows. Primary osteoporosis is most common in:
a. Elderly men
b. Young children
c. Young menstruating women
d. Elderly, postmenopausal women

RATIONALE:Primary osteoporosis is most notable in women who have gone through

menopause, but can affect anyone in advanced age. Age-related changes to bone mass
and bone structure can affect both the spongy interior bone (called cancellous or
trabecular bone), the hard exterior bone (called cortical bone), or both.

89. A client undergoes a muscle biopsy. After the procedure, the nurse must keep the biopsy
site elevated for:
a. 2 to 4 hours
b. 6 to 8 hours
c. 12 hours
d. 24 hours
RATIONALE:
https://quizlet.com/134200157/musculoskeletal-disorders-nclex-428-flash-cards/

90. A client with gouty arthritis is prescribed a low-purine diet. The nurse should instruct this
client to avoid:
 a. Organ meats
b. Citrus fruits
c. Green vegetable
d. Fresh fish

RATIONALE: Organs are high in purine

https://quizlet.com/134200157/musculoskeletal-disorders-nclex-428-flash-cards/

91. Which of the following nursing diagnoses would the nurse choose for a client with
multiple sclerosis (MS), regardless of type or severity?
a. Impaired Gas Exchange
b. Acute pain
c. Risk for aspiration
d. Fatigue

RATIONALE: Symptoms include loss of vision in an eye, loss of power in an arm or

leg or a rising sense of numbness in the legs. Other common symptoms associated
with MS include spasms, fatigue, depression, incontinence issues, sexual dysfunction,
and walking difficulties
https://quizlet.com/75218890/musculoskeletal-flash-cards/

92. The nurse is planning care for a client with multiple sclerosis and plans to teach about
which of the following medications if ordered by the physician
a. Antihistamines
b. Interferon
c. Levodopa
d. Antibiotics

RATIONALE: Interferons are substances produced by cells in the body to help fight
infections and tumors

93. A client seeks treatment in the emergency department for a lower leg injury. There is
visible deformity to the lower aspect of the leg, and the injured leg appears shorter than
the other leg. The area is painful, swollen, and beginning to become ecchymotic. The
nurse interprets that this client has experienced a:
a. Strain
b. Sprain
c. Fracture
d. Contusion

RATIONALE:
A: Strain is when a muscle is stretched too much and tears. It is also called a pulled
muscle.
 B: A sprain is a stretching or tearing of ligaments — the tough bands of fibrous tissue
that connect two bones together in joints.
D: A contusion, or bruise, is caused by a direct blow to the body that can cause damage
to the surface of the skin and to deeper tissues as well depending on the severity of the
blow.

94. The nurse is assessing the client who has just been measured and fitted for crutches.
The nurse determines that the client’s crutches are fitted correctly if:
a. The top of the crutch is even with the axilla
b. The elbow is straight when the hands is on the handgrip
c. The client’s axilla is resting on the crutch pad during ambulation
d. The elbow is at a 30-degree angle when the hand is on the handgrip.
RATIONALE:

95. The nurse discussed to Karen the nature of rheumatoid arthritis. Which of the following
statements by the client indicate a correct understanding of the disease process?
a. The nodules under my skin behind my forehead is part of RA
b. I have to be careful because my bones have become brittle
c. I have been working very hard lifting heavy things while selling in the market
d. My disease is a normal aspect of my aging
RATIONALE: Persistent stiffness, tenderness, and pain in joints may be an early sign of
rheumatoid arthritis.

96. The nurse should include which of the following client teachings for prevention of rapid
progression of osteoporosis?
a. Avoid taking skim milk
b. Avoid taking protein-rich foods
c. Avoid calcium supplement
d. Avoid alcohol
RATIONALE: avoiding alcohol and cigarette smoking will prevent rapid progression of
osteoporosis. Skim milk is indicated among elderly because it is low in fats. Protein
foods are necessary for calcium absorption. Calcium supplements help maintain integrity
of the bones.
https://quizlet.com/332527825/pcc-2-test-1-osteoporosis-questions-flash-cards/

97. A client is brought to the emergency room with compound femur fracture. What is the
first action the emergency room nurse should do?
a. Cover the open wound
b. Check the client's blood pressure
c. Assess the client’s neurologic status
d. Prepare the client for x-ray

RATIONALE:compound fracture of the femur may cause severe internal bleeding.

Internal bleeding is characterized by hypotension.
 https://quizlet.com/22357638/oa-fractures-flash-cards/

98. A 3-year old in Bryant’s traction is with foot foam. You found the child pulling out the foot
foam. What is your most appropriate nursing action?
a. Remove the foot foam and assess the area
b. Reapply the foot foam at once
c. Call another nurse to maintain traction as you reapply
the foot foam
d. Tell the child to stop removing the foot foam

RATIONALE: maintain the traction as the foot foam is reapplied.

https://quizlet.com/22357638/oa-fractures-flash-cards/

99. How do you position a client with a left hip fracture in Buck’s traction?
a. Head of bed raised at 45 degree angle
b. Left calf on pillow from knee to ankle
c. Position the left on affected side with pillows between legs
d. Position the left in the center of the bed with the leg extended

RATIONALE: elevate the leg with a pillow to relieve pressure from the heel of the foot
and to improve the effectiveness of the countertraction.
https://quizlet.com/216546665/hip-fracture-bucks-traction-questions-flash-cards/

100. A patient had hip surgery. On the second post-op day, the patient is agitated, is
tremulous and confused. What should the nurse primarily assess?
a. The surgical wound
b. Alcohol use before surgery
c. Peripheral circulation
d. Breathing pattern

RATIONALE: the client's sign and symptoms indicate alcohol withdrawal.

https://quizlet.com/216546665/hip-fracture-bucks-traction-questions-flash-cards/