Question 1

To prevent venous stasis, a client is to be measured for knee-high anti-embolus stockings. Which of the following are appropriate nursing actions?

Accepted Answer

Answer reason: Proper sizing of anti-embolus (TED) stockings requires measuring limb circumference at key points to apply graduated compression without impairing arterial flow. The ankle is the narrowest part of the lower leg and is routinely used to determine the correct stocking size and ensure appropriate pressure gradient. In contrast, measuring heel-to-gluteal fold corresponds to thigh-high length, not knee-high fitting, and foot length is not a standard parameter for TED sizing. Measuring heel to popliteal space addresses length, but circumference (especially at the ankle) is essential to select the correct size and prevent constriction or ineffective compression.

Question 2

When instructing a patient on deep breathing and coughing, the nurse explains that the patient should be sitting for these activities because?

Accepted Answer

Answer reason: Upright positioning promotes maximal lung expansion by improving diaphragmatic descent and ventilation to dependent lung areas. This increases airflow behind retained mucus, helping mobilize and clear secretions during coughing and reducing atelectasis risk. Comfort alone is not the primary clinical rationale for the position, and incision support can be done in any position using splinting. The key safety goal is enhancing effective airway clearance and gas exchange through better mechanics in sitting.

Question 3

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client indicates an understanding of the nurse’s instructions?

Accepted Answer

Answer reason: After thyroidectomy, supporting the neck during coughing and position changes reduces tension on the incision and helps prevent strain and discomfort. This technique helps maintain alignment and minimizes risk of wound stress while the tissues are healing. Antithyroid drugs are not routinely continued after removal of the thyroid; instead the more common long-term need is thyroid hormone replacement depending on extent of resection. Tingling around the lips/fingers/toes suggests hypocalcemia from potential parathyroid injury and should be reported immediately to the surgical team, but the statement’s “go to the emergency room” framing is not the standard postoperative instruction compared with contacting the provider promptly.

Question 4

Which is a nursing diagnosis?

Accepted Answer

Answer reason: This option reflects a functional limitation affecting movement and ability to perform activities, which can be addressed with mobility assistance, positioning, exercise, and safety planning. The other options are medical diagnoses identifying diseases (infection, chronic blood pressure disorder, and metabolic disease) that require provider-led medical management. Therefore, the best nursing diagnosis among the choices is the one centered on patient function and nursing-managed outcomes.

Question 5

A patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient's care plan?

Accepted Answer

Answer reason: After axillary node dissection, the affected arm is at higher risk for impaired lymphatic drainage, swelling, and discomfort. Elevating the operative-side arm helps promote venous/lymphatic return and reduces edema while supporting comfort and healing. In contrast, using the operative-side arm for blood pressure measurement or venipuncture increases the risk of lymphedema and tissue injury due to compromised lymph flow. Routine dressing assessment is important, but the key plan-of-care priority specific to this surgery is protection and positioning of the affected extremity to prevent swelling and complications.

Question 6

The nurse cares for a client with a fractured hip awaiting surgical correction. What interventions does the nurse include to reduce pain preoperatively?

Accepted Answer

Answer reason: Immobilization is a key principle for fracture pain control because movement at the fracture site increases tissue irritation and muscle spasm. Traction helps align the injured structures and limits painful motion while reducing spasm, which can significantly decrease discomfort while awaiting surgery. Passive range of motion of the affected extremity would tend to increase movement at the injury and worsen pain. Regular ibuprofen is less appropriate preoperatively due to bleeding risk and is not the primary nursing intervention emphasized for acute hip fracture stabilization.

Question 7

The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?

Accepted Answer

Answer reason: Immediately post-amputation, positioning should prioritize preventing hemorrhage and edema while protecting the incision and promoting safe alignment. Slight elevation of the residual limb decreases swelling and supports venous return without placing the hip in flexion that can contribute to contracture risk. Side-lying on the operative side helps reduce hip flexion/abduction tendencies and supports proper stump positioning early after surgery. In contrast, elevating only the foot of the bed or using reverse Trendelenburg does not directly control residual-limb edema and may not provide optimal stump support.

Question 8

The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?

Accepted Answer

Answer reason: Confidence is also essential because fear or hesitancy commonly leads to poor sequencing, reduced weight-bearing, and unsafe compensatory movements. Stamina is helpful but is not the immediate predictor of whether the first attempts with a cane will be safe. Full range of motion and feelings about using the cane may affect long-term function and adherence, but they are not the primary safety screen before initiating training.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Mobility-Immobility Practice Test 8

Mobility-Immobility NCLEX Practice Test

Continue Learning

To prevent venous stasis, a client is to be measured for knee-high anti-embolus stockings. Which of the following are appropriate nursing actions?

When instructing a patient on deep breathing and coughing, the nurse explains that the patient should be sitting for these activities because?

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client indicates an understanding of the nurse’s instructions?

Which is a nursing diagnosis?

A patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient's care plan?

The nurse cares for a client with a fractured hip awaiting surgical correction. What interventions does the nurse include to reduce pain preoperatively?

The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?

The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?

Think you’re ready for the NCLEX?

Leave a Reply Cancel reply

Practice Questions

Study Cards

Flashcards