NCLEX RN Questions: Musculoskeletal Injuries (61-65)

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61. 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

62. 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, sensation, movement, capillary refill, and pulse of the affected extremity

63. A client in the emergency department has a cast applied. 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

64. 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

65. 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






NCLEX RN Questions
Answers and Rationale

61) B
- A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified.

62) D
- A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

63) D
- The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

64) C
- The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client.

65) C
- Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX RN Questions about Musculoskeletal Injuries (1-8)


Or proceed to the next set of questions:

NCLEX RN Questions about Musculoskeletal Injuries (66-70)


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