ORTHOPEDIC NCLEX
1. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
2. A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
3. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?
4. The nurse takes a client’s temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?
5. The nurse is doing a routine assessment of a client’s peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
6. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
7. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
8. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?
9. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?
10. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?
11. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?
12. The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
13. The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client’s fears and misconceptions about surgery?
14. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?
15. The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client’s blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed?
16. A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
17. The nurse is monitoring an adult client for postoperative complications. Which is mostindicative of a potential postoperative complication that requires further observation?
18. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?
19. The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain?
20. The nurse checks the client’s surgical incision for signs of infection. Which is indicative of a potential infection?
21. The nurse is checking a client’s surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse?
22. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which first action?
23. The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?
24. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?
25. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?
26. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?
27. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?
28. The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement?
29. The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform? Select all that apply.
30. The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?
31. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which?
32. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?
33. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
34. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?
35. The nurse witnesses a client sustain a fall and suspects that the client’s leg may be fractured. Which action is the priority?
36. A client with a hip fracture asks the nurse why Buck’s extension traction is being applied before surgery. The nurse’s response is based on the understanding that Buck’s extension traction has which primary function?
37. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
38. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first?
39. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?
40. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection?
41. 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 was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?
42. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?
43. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?
44. The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply.
45. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?
46. The nurse is evaluating the client’s use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?
47. The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?
48. A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?
49. The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?
50. The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client’s bedside?
51. The nurse notes the appearance of skin breakdown on a client’s hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.
52. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, “I don’t feel any better than I did before surgery.” Which response by the nurse is most appropriate?
53. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement?
54. A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown?
55. A client has been placed in Buck’s extension traction. Which technique provided by the nurse will provide countertraction?
56. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
57. The health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank. Round the answer to the nearest whole number.
58. The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?
59. The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?
60. The nurse is explaining The Joint Commission’s (TJC’s) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?
61. A client who had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.
62. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client?
63. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful?
64. The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight “puffiness” along the edges and is non-reddened with no apparent drainage. The client’s temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?
65. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?
66. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which?
67. A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client’s history?
68. A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, “I think I’m going crazy. I can feel my left foot itching.” How does the nurse correctly interpret the client’s statement?
69. The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done?
70. A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action?
71. A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?
72. A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor?
73. The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium?
74. The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder?
75. A client is treated in the health care provider’s office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours?
76. The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?
77. The nurse in the health care provider’s office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?
78. A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client’s vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which?
79. A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?
80. One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.
81. The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
82. A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.
83. The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply.
84. Intravenous (IV) lactated Ringer’s (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?
85. The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?
86. A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?
87. The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?
88. A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?
89. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). Which should the nurse anticipate as the likely initial treatment?
90. The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?
91. The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication?
92. The nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which as a normal finding?
93. The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client?
94. A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure?
“95. 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. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury?
96. The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room?
97. The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting?
98. The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan?
99. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question?
100. The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
101. A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?
102. A client has Buck’s extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device?
103. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm?
104. The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?
105. The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?
106. A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most?
107. A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed?
108. A client with right-sided weakness needs to learn how to use a cane. How should the nurse teach the client to position the cane?
109. A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance?
110. The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?
111. The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes?
112. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client?
113. A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client?
114. The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?
Apply a knee immobilizer before getting the client up, and elevate the client’s surgical leg while sitting.
115. A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?
116. A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure?
117. A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client’s needs should best be addressed by referral to which service?
118. The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?
119. A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?
120. A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?
121. The nurse is caring for a client diagnosed with Paget’s disease. The nurse plans care, knowing that this condition usually affects which bones?
122. The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin?
123. The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?
Maintaining body weight at or above minimum recommended levels
124. The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
120.) A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?
121.) The nurse is caring for a client diagnosed with Paget’s disease. The nurse plans care, knowing that this condition usually affects which bones?
122.) The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin?
123.) The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?
124.) The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
125.) The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder?
126.) The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?
127.) The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus?
128.) A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site?
129.) The nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?
130.) A client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which observation on inspection of the client’s leg?
131.) A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?
132.) A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement?
133.) The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action?
134.) A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which?
135.) The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?
136.) The nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding?
137.) The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?
138.) The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the
