NCLEX Case Study: Nursing Care of the Patient With a Musculoskeletal Disorder

By March 18, 2018 No Comments

Kayla, a 55-year-old female, has been overweight her entire life. She was admitted to the orthopedic unit earlier in the day for a knee replacement (arthroplasty) and has been allowed nothing by mouth since midnight.While going through her preoperative checklist, the nurse finds that Kayla’s complete blood count (CBC) is within normal limits (WNL); urinalysis is negative for a UTI; and her electrolytes, BUN, and creatinine are normal. Kayla’s outpatient chest x-ray and EKG are normal. Kayla is a nonsmoker. She has a past medical history of HTN and has taken her BP medication this morning with a sip of water as instructed. Kayla is anxious,because she has never had surgery.It was also decided preoperatively that she would do her rehabilitation in an inpatient facility owing to her obesity and history of immobility.

Following surgery, Kayla is taken to the post-anesthesia care unit (PACU) for 2 hours and is now on the orthopedic floor.


Place the postoperative nursing care issues in priority order from 1 to 6:
_______ Administer pain medication
_______ Monitor input and output (I&O)
_______ Monitor for deep vein thrombosis (DVT)
_______ Start continuous passive range of motion (ROM) to prevent contractures
_______ Facilitate early ambulation
_______ Monitor for bleeding at the site

Kayla is doing well on postoperative day 1. Repeat blood work has been ordered to include a CBC, electrolytes, BUN, and creatinine. The nurse is reviewing Kayla’s vital signs as well as her input and output (I&O) for the previous 8 hours.


Which finding will the nurse report to the health care provider (HCP)?
A. Blood urea nitrogen (BUN): 22 mg/dL
B. Blood pressure (BP): 108/72 mmHg
C. Urine output: 30 mL/hr
D. Hemoglobin: 12.8 g/dL

Kayla’s lab work, vital signs, and urine output are WNL. A nutritionist is consulted to help her lose weight to ensure surgical success.

On the second postoperative day, Kayla complains of pain in the unaffected leg and points to her calf.The nurse notes that the calf is warm and tender to palpation.A Dop- pler study of the extremity is ordered. It is positive for deep vein thrombosis (DVT).The nurse notifies the HCP and obtains an order for a heparin drip.


The prescriber’s order calls for heparin infusion at 1,800 units/hr. The label on the intravenous (IV) bag
reads: Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose?
A. 120mL/hr
B. 90mL/hr
C. 85mL/hr
D. 73mL/hr

The nurse understands that Kayla is at risk for a pulmonary embolism (PE) secondary to the DVT.

Select all that apply:

Which clinical manifestations are associated with a pulmonary embolus?
A. Bradycardia B. Dyspnea
C. Backpain
D. Diaphoresis
E. Anxiety
F. Tachypnea

The heparin drip has been initiated, and Kayla is resting comfortably.The nurse under- stands that bleeding precautions must be initiated for patients on heparin therapy.

Select all that apply:

Which of the following constitute bleeding precautions?
A. Hemoccult all stool
B. Give all meds via intramuscular (IM) route
C. Limit blood draws
D. Use an electric razor


Which medication would the nurse administer as the antidote to heparin?
A. VitaminK
B. Protaminesulfate C. Aspirin
D. Erythropoietin

Rebecca, a 20-year-old female, is admitted to the orthopedic floor with a compound femur fracture secondary to a skiing accident. She is complaining of severe pain rated at nine out of 10. The orthopedic surgeon determines that Rebecca’s fracture requires open reduction and internal fixation (ORIF). She is taken to the operating room, where her bone is pinned and an immobilizer is placed on her leg.


What is the priority nursing diagnosis for a patient with an open reduction and internal fixation (ORIF)?
A. Risk for constipation
B. Risk for infection
C. Activityintolerance
D. Risk for injury

Rebecca is doing well on postoperative day 1.The nurse prepares to assist Rebecca out of bed for the first time since her surgery.


Before assisting a patient with open reduction and internal fixation (ORIF) in ambulation for the first time, the nurse will:
A. Review the postoperative orders for weight-bearing status
B. Use a mechanical lift to transfer from bed to chair
C. Administer pain medication 3 hours before ambulation
D. Encourage patient to empty bladder to minimize interruption

Rebecca is happy that she does not need traction. She will be sent home in a wheelchair with an immobilizer. She will need to follow up with the orthopedic outpatient center in a week.

Boylan, a 78-year-old war veteran, is seen in the outpatient orthopedic center. He has had type 1 diabetes mellitus for a long time and suffers from peripheral vascular disease. He is scheduled for a right above-the-knee amputation (AKA) and has been admitted to the medical inpatient unit.

Fill in the blank:

In caring for a patient with an amputation, the nurse should place a ___________________ at the bedside for emergency use.

Boylan’s surgery went well and, after a short time in the PACU, he is admitted to the orthopedic floor.The nurse understands that Boylan, like all surgical patients, is at risk for complications, particularly given his history of type 1 diabetes mellitus.

Select all that apply:

To reduce the patient’s risk for surgical complications, the nurse will:
A. Monitor blood glucose levels
B. Encourage use of an incentive spirometer every 2 hours
C. Administer insulin as prescribed
D. Assess heart and lung sounds
E. Administer metformin (Glucophage)
F. Mark dressing if any bleeding occurs

Select all that apply:

During the first 24 hours following a right above-the-knee amputation (AKA), the nurse will:
A. Place the patient in the Trendelenburg position
B. Monitor vital signs and surgical site
C. Elevate the amputated limb with pillows
D. Monitor input and output (I&O)
E. Administer pain medication as needed
F. Keep amputated limb flat on the bed


In patients with diabetes mellitus, the nurse understands to monitor for which complication?
A. Edema of the stump
B. Mild erythema of the incision
C. Separation of the surgical wound edges
D. Bleeding to surgical stump dressing

After his amputation, the nurse offers Boylan a number of instructions. She explains that after healing is complete and the residual limb is well molded, he will be fitted with a prosthesis.


The nurse determines that teaching has been effective when the patient says:
A. “I should lie on my abdomen for 30 minutes three to four times a day.”
B. “I should change the shrinker bandage when it becomes soiled or stretched out.”
C. “I should use lotion on the stump to prevent drying and cracking of the skin.”
D. “I should elevate the limb on a pillow most of the day to decrease swelling.”

Postoperatively, the nurse monitors Boylan’s left foot carefully with tests such as angi- ography, ankle-brachial indexes, Doppler ultrasound, and transcutaneous oxygen pressures. Boylan receives pain medication for occasional phantom limb pain. He is attending physical therapy to strengthen his upper body and improve circulation in the left leg.

TIP: Bandaging of an above-the-knee amputation (AKA)

Use figure-eight bandaging of an AKA amputation to promote shaping and molding for a prosthesis.

TIP: Patient teaching

In order to minimize edema, teach the patient who had a below-the-knee amputation (BKA) to avoid dangling the residual limb over the bedside.

Michelle, age 66 years, regularly seeks treatment at the outpatient orthopedic clinic for osteoarthritis of the hands and spinal osteoporosis.

Select all that apply:

Risk factors for osteoporosis include:
A. Postmenopausalfemale
B. History of smoking
C. Asianethnicity
D. Male older than 60 years
E. History of strength-training exercises
F. Sedentary lifestyle


What is the leading cause of osteoporosis?
A. Progesteronedeficiency
B. Vitamin D deficiency
C. Folic acid deficiency
D. Estrogendeficiency

Treatment for osteoporosis is aimed at preserving bone mass, preventing fractures, maintaining function, and decreasing pain. Michelle is prescribed medications for the management of her osteoporosis and osteoarthritis.


Which instructions will the nurse include in teaching about alendronate (Fosamax)?
A. Take with food and a full glass of water
B. Take at bedtime with a full glass of water
C. Take before breakfast and remain upright for 30 minutes after ingestion
D. Lie down for at least 30 minutes after ingestion

Michelle asks the nurse about any adverse effects associated with Fosamax.


When teaching about adverse effects, a patient taking alendronate (Fosamax) should be instructed to report
A. Dysphagia
B. Poorappetite C. Insomnia
D. Tinnitus

In addition to medication, the nurse discusses lifestyle modification with Michelle to minimize further damage and maintain optimal function.

Select all that apply:

For patients with osteoporosis, lifestyle modification includes:
A. Regular, weight-bearing exercise
B. Intake of calcium-rich foods
C. Altering home environment for safety
D. Routine bedrest to prevent pain

Michelle reports being upset when the osteoarthritis in her hands prevents her from knitting or crocheting.

Select all that apply:

Which interventions will minimize the pain and inflammation commonly associated with osteoarthritis?

A. Encourage adequate sleep each night
B. Encourage regular rest periods throughout the day
C. Splint hands to immobilize acutely inflamed joints
D. Use Tylenol (acetaminophen) as needed for pain
E. Promote regular physical activity
F. Avoid warm packs at all times

Michelle is prescribed glucosamine sulfate and Tylenol (acetaminophen) as needed for pain or discomfort.


The action of glucosamine sulfate is to:
A. Rebuild cartilage in the joint
B. Decrease inflammation of the joint
C. Stabilize the joint
D. Provide a heat effect to the joint

She will return for follow-up in 1 month to evaluate for side effects and tolerance of glucosamine sulfate.

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