Deck 39: Promoting Musculoskeletal Function

Question 1

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

A) raise the head of the bed to 30 to 45 degrees.
B) set the proper flexion and extension limits.
C) elevate the machine at the foot of the bed on one pillow.
D) keep the operated knee warm.

Answer 1

set the proper flexion and extension limits.

Question 2

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

A) "Take off the rubber tips of the crutches while using stairs."
B) "Rest the axillae on the axillary bar of the crutch."
C) "Bring the good leg up first when going up stairs."
D) "Move the good leg and the crutches together."

Answer 2

"Bring the good leg up first when going up stairs."

Question 3

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

A) put the bed in the lowest position.
B) position the sling under the patient from the top of the head to the buttocks.
C) lower the far bed rail.
D) widen the stance of the lift's base and lock it.

Answer 3

widen the stance of the lift's base and lock it.

Question 4

A patient needs to have a triangular bandage applied. The nurse should position the sling so that the hand is _____ inch(es) below the elbow.

A) 1
B) 2
C) 4
D) 6

Question 5

A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by:

A) elevating the leg on one to two pillows.
B) petaling the edges of the cast.
C) placing the patient in high Fowler's position.
D) speeding the drying with a hair dryer.

Question 6

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

A) low oxygen saturation.
B) atelectasis.
C) hypostatic pneumonia.
D) respiratory alkalosis.

Question 7

A nurse performing a head to toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

A) capillary refill of 3 seconds.
B) palpable peripheral pulses.
C) warm feet and hands.
D) numbness of distal limb.

Question 8

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

A) notify the charge nurse of possible infection.
B) wipe off drainage with a damp wash cloth.
C) assure the patient that such drainage is expected.
D) cover the pin with several gauze pads and tape securely.

Question 9

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

A) vasodilation.
B) compression of muscles on venous walls.
C) increased metabolism.
D) maintaining strength in muscles.

Question 10

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

A) 5 to 15 degrees
B) 15 to 30 degrees
C) 30 to 45 degrees
D) 45 to 60 degrees

Question 11

The nurse assesses a patient as having delayed capillary refill if the blanching lasts longer than:

A) 1 second.
B) 2 seconds.
C) 3 seconds.
D) 5 seconds.

Question 12

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

A) a spinal cord injury.
B) recurrent pressure ulcers.
C) burns that have been newly grafted.
D) severe arthritis.

Question 13

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

A) feet resting against the foot of the bed.
B) weights hanging free in the air.
C) knee gatch raised.
D) head of bed elevated 20 degrees.

Question 14

A nurse applying a pressure bandage for a patient should terminate the wrap by a:

A) spiral reverse turn.
B) circular turn.
C) spiral turn.
D) figure of eight turn.

Question 15

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

A) 30 minutes.
B) 60 minutes.
C) 4 hours.
D) 24 hours.

Question 16

The daughter of an older woman with a diagnosis of a fractured tibia asks why her mother is in Buck's traction. The nurse's most informative response would be that Buck's traction:

A) helps the bone heal more quickly.
B) allows for large traction weights to reduce the fracture.
C) does not cause skin disruptions.
D) reduces muscle spasm that accompanies fractures.

Question 17

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

A) fingertips and palms.
B) palms only.
C) fingertips and flat parts of fingers.
D) palms and flat parts of fingers.

Question 18

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

A) urinary stasis.
B) friction.
C) constipation.
D) contractures.

Question 19

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

A) face the patient and wrap from proximal to distal.
B) adjust the pressure or tension as needed.
C) use metal clips to secure the wrap.
D) overlap turns of the bandage equally.

Question 20

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

A) moist and pink.
B) dry and dirty.
C) moist and white.
D) dry and greenish.

Question 21

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

A) protecting the cast from soiling.
B) easing itching under the cast by scratching with a bent coat hanger.
C) grasping the cast over the leg to help in turning.
D) using the spreader bar to turn the patient.
E) turning frequently to the prone position.

Question 22

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

A) rubber sheets.
B) alcohol rubs to the heels.
C) sheepskin pads.
D) water mattresses.
E) pulsating air pads.

Question 23

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

Question 24

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

Question 25

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

A) left the brakes of the wheelchair unlocked.
B) placed the patient's feet centered on the footrests.
C) placed slippers on the patient.
D) left the patient with the lap robe tucked underneath.

Question 26

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

A) spray pin insertion with antimicrobial solution.
B) clean closest to the skin puncture site in a circular motion.
C) slightly rotate each pin to prevent adhesion to the bone.
D) secure ends of wire with cork or adhesive tape.
E) accomplish care with clean technique.

Question 27

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

Question 28

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

A) pressure injuries.
B) loss of bone mass.
C) urinary infection.
D) pneumonia.
E) permanent loss of function.