Question 1

Which nursing intervention is appropriate after a total knee replacement?

Accepted Answer

Answer reason: C. Use a continuous passive motion (CPM) machine as ordered Post–total knee replacement care promotes early mobility and joint range of motion to reduce stiffness and improve functional recovery. CPM may be prescribed to gently move the joint through a controlled range, supporting circulation and decreasing risk of contractures. Keeping the knee flexed or placing pillows under the knee promotes flexion contracture, and avoiding leg exercises delays rehabilitation and increases complication risk (e.g., venous stasis).
Category reason: This item tests appropriate postoperative nursing care to support mobility and prevent immobility-related complications after orthopedic surgery, fitting NCLEX Physiological Integrity → Basic Care and Comfort → Mobility-Immobility.

Question 2

A nurse is caring for a client 12 hours after abdominal surgery. Which nursing action is the priority for preventing deep vein thrombosis (DVT)?

Accepted Answer

Answer reason: Early ambulation is the most effective nursing intervention to reduce venous stasis after surgery, directly addressing a key mechanism of postoperative DVT formation. Mobilization activates the calf muscle pump, improving venous return and decreasing clot risk more reliably than passive measures alone. TED stockings can be helpful adjuncts, but they do not replace the benefit of walking when the client is able. Incentive spirometry targets pulmonary complications, and giving opioids may facilitate activity but is not itself a primary DVT-prevention action.
Category reason: This is a postoperative nursing-priority question focused on preventing a complication through an intervention (mobilization), which aligns with nursing care in Mobility-Immobility under Basic Care and Comfort.

Question 3

Identify the comfort device which helps to prevent foot drop?

Accepted Answer

Answer reason: Prolonged bed rest can allow the feet to rest in plantar flexion, predisposing to contracture at the ankle and resulting in foot drop. A footboard provides firm support that maintains the ankle in neutral (dorsiflexed) alignment and helps prevent this complication. Air cushions are used primarily for pressure redistribution, and a bed cradle lifts linens off the body rather than positioning the foot/ankle. A foot block is not the standard device name used for preventing foot drop compared with a footboard.
Category reason: This question tests a nursing comfort/positioning device used to prevent an immobility-related complication (foot drop), which is a Basic Care and Comfort—Mobility/Immobility concept.

Question 4

The logroll turning method is used in?

Accepted Answer

Answer reason: The logroll technique keeps the head, neck, and trunk aligned as one unit to prevent spinal rotation, flexion, or extension that could worsen cord or vertebral injury. It is used for patients with suspected or confirmed spinal trauma and during spinal precautions for turning, linen changes, and skin assessment. Conditions like lung abscess, epilepsy, or stroke do not inherently require strict spinal alignment during repositioning unless there is a concurrent spine instability.
Category reason: This question tests a nursing mobility/positioning intervention used to maintain spinal alignment and prevent complications during patient turning, which fits NCLEX Basic Care and Comfort—Mobility-Immobility.

Question 5

A client with Parkinson disease was provided with home care instructions about measures to control a right-sided hand tremor by the nurse. Which instruction should the nurse give to the client?

Accepted Answer

Answer reason: Providing a purposeful activity for the affected hand can help manage tremor by promoting controlled, repetitive movement and improving functional use. Using an object to grasp can also offer proprioceptive input and slight resistance that may dampen tremor during activity. Telling the client to use only one hand (either side) unnecessarily limits function and can worsen disability. Sleeping position does not directly address controlling an action tremor during daily tasks.
Category reason: This item asks for an appropriate nursing home-care instruction to help manage Parkinson-related tremor, which is a functional mobility/coordination intervention in day-to-day care.

Question 6

Which nursing intervention is appropriate to prevent pulmonary embolus in a patient who is prescribed bed rest?

Accepted Answer

Answer reason: D. Teach the patient to move legs in bed Immobility increases venous stasis in the lower extremities, raising the risk of DVT that can embolize to the lungs. Regular leg exercises (ankle pumps, flexion/extension) promote venous return via the calf-muscle pump and reduce clot formation risk. Limiting fluids can worsen hemoconcentration, deep breathing/coughing targets atelectasis rather than venous thromboembolism prevention, and elevating the knees (knee gatch) can impede venous return by compressing popliteal veins.
Category reason: The question asks for a nursing intervention to prevent a complication of immobility during prescribed bed rest, which centers on mobility measures and prevention of venous stasis in patient care.

Question 7

After a mastectomy, how should the affected arm be positioned?

Accepted Answer

Answer reason: C. Elevated above heart level Elevation promotes venous and lymphatic drainage from the operative side, reducing edema and discomfort after lymph node disruption. Keeping the limb above the level of the heart decreases fluid accumulation and helps prevent complications such as increased swelling and impaired wound healing. Dependent positioning or compressing the arm against the chest can worsen swelling and compromise circulation.
Category reason: This question tests a postoperative nursing intervention (positioning) to prevent swelling and support recovery after surgery, which is patient-care focused and fits NCLEX Physiological Integrity (mobility/positioning).

Question 8

Which Position Best for Patient with difficulty breathing?

Accepted Answer

Answer reason: Upright positioning maximizes chest expansion by lowering diaphragm pressure from abdominal contents and improving ventilation/perfusion, which reduces work of breathing. It also helps patients use accessory muscles more effectively and can improve oxygenation in dyspnea from many causes (e.g., COPD, pulmonary edema). Supine can worsen dyspnea by reducing lung volumes, and prone/lithotomy are not standard first-line comfort positions for acute breathing difficulty.
Category reason: This question tests a nursing intervention (patient positioning) to improve breathing and comfort, which falls under basic care/comfort and mobility-related positioning decisions in NCLEX patient care.

Question 9

Which action is best to prevent pressure ulcers in a bed-bound patient?

Accepted Answer

Answer reason: Regular turning/offloading relieves sustained pressure over bony prominences, restores capillary blood flow, and reduces ischemic tissue injury—the core mechanism of pressure ulcer formation. Massage over reddened/nonblanchable areas can further damage fragile capillaries and worsen tissue injury. Donut cushions can concentrate pressure at the ring edges and impair circulation. A head-of-bed at 90° increases shear and sacral pressure; if elevated, it is typically kept as low as tolerated (often ≤30°) to reduce shear.
Category reason: This question tests a nursing intervention to prevent complications of immobility (pressure injury prevention) in a bed-bound patient, which fits Mobility-Immobility under Basic Care and Comfort.

Question 10

Why does turning a patient every 2 hours prevent pressure ulcers from developing?

Accepted Answer

Answer reason: Pressure ulcers form when prolonged pressure compresses capillaries, reducing perfusion and tissue oxygenation and leading to ischemia and necrosis. Regular repositioning redistributes pressure, restoring microcirculation and oxygen delivery to vulnerable skin and subcutaneous tissues. This also reduces the duration of shear and pressure over bony prominences, lowering injury risk. The other options do not address the key mechanism of preventing ischemia from sustained capillary occlusion.
Category reason: This question tests a nursing intervention (scheduled repositioning) to prevent immobility-related complications like pressure injuries, which fits Mobility-Immobility under Basic Care and Comfort.

Question 11

A nurse is caring for a client with osteoporosis. Which instruction is most important to prevent fractures?

Accepted Answer

Answer reason: b) Increase calcium and vitamin D intake Calcium and vitamin D support bone mineralization and help slow bone loss, reducing fragility fracture risk in osteoporosis. Weight-bearing exercise is typically encouraged (as tolerated) because it promotes bone strength, so avoiding it is not protective. Limiting fluids is unrelated and can increase risks such as dehydration and falls. Stretching can improve flexibility and balance; it is generally not contraindicated and may help prevent falls when done safely.
Category reason: This item tests nursing teaching to reduce injury risk in a client with osteoporosis, focusing on interventions to prevent fractures, which aligns with patient care for mobility and safety in Physiological Integrity.

Question 12

A nurse is assisting a client with ambulation using a cane. Where should nurse stand?

Accepted Answer

Answer reason: Standing on the weaker side allows the nurse to provide direct support where the client is most likely to lose balance and to guard against falls. The cane is typically used on the stronger side to widen the base of support and reduce load on the weak leg, so the nurse should not compete for space on that side. This positioning lets the nurse use a gait belt and control the client’s center of gravity if the weak leg buckles. It is a standard mobility-safety technique to maximize stability during ambulation.
Category reason: This question tests safe nursing assistance during ambulation with an assistive device, focusing on patient mobility and fall prevention, which fits Mobility-Immobility under Basic Care and Comfort.

Question 13

The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?

Accepted Answer

Answer reason: Adequate pain control improves ability to move, breathe effectively, and participate in early ambulation by reducing guarding and sympathetic stress responses after surgery. Premedicating shortly before activity helps prevent activity-limiting pain and can reduce the risk of complications from immobility (e.g., atelectasis, venous thromboembolism). Removing telemetry is unsafe after cardiac surgery because monitoring is indicated during mobilization, and a walker is not routinely required unless the client has weakness or balance issues. Coughing and deep breathing are important postoperative interventions but do not directly improve tolerance for walking as effectively as targeted analgesia.
Category reason: This is a nursing-intervention question focused on promoting safe, tolerable postoperative ambulation and managing comfort to support mobility, which aligns with NCLEX Physiological Integrity: Basic Care and Comfort (Mobility-Immobility).

Question 14

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?

Accepted Answer

Answer reason: Redness over the sacrum in a wheelchair user suggests early pressure injury risk from prolonged pressure and shear. Regular repositioning offloads bony prominences, restores tissue perfusion, and is the most immediate, high-impact prevention strategy. Vitamins and increased fluids can support overall skin health but do not address the primary cause (unrelieved pressure). A newer wheelchair may help if poorly fitted, but prompt turning/repositioning education is the priority nursing instruction.
Category reason: This question focuses on a nursing intervention to prevent pressure injury in an immobile client by teaching frequent repositioning, which fits Mobility-Immobility within Basic Care and Comfort.

Question 15

A patient's outcome at the end of the shift is to ambulate down the hall and back twice. By the end of the shift the patient was able to ambulate once. Since the outcome was not met, what would be the best recommendation to change the care plan?

Accepted Answer

Answer reason: B. Change the care plan to ambulate once per shift The care plan should be revised to a realistic, measurable goal that matches the patient’s demonstrated current ability while still promoting progress. Since the patient achieved one hallway ambulation, adjusting the goal to that level supports adherence and allows gradual advancement without overexertion. Raising the target to three times increases risk of fatigue, pain, or falls, and seeking a provider’s advice is not the first step when the immediate issue is goal modification based on nursing evaluation.
Category reason: This item asks how to revise a nursing care plan and mobility goal based on evaluation of patient progress, which is a patient-care judgment within Mobility-Immobility.

Question 16

Which of the following is a correct expected outcome of a nursing diagnosis?

Accepted Answer

Answer reason: Expected outcomes for nursing diagnoses should be patient-centered and written in SMART format (specific, measurable, achievable, relevant, time-bound). This option is specific (ambulate the hall and back), measurable (3 times), and time-limited (by end of shift), making it an appropriate outcome statement. The other options are vague ("feel better"), not clearly measurable/operationalized, or not sufficiently time-bound/quantified to evaluate progress reliably during the shift.
Category reason: This item tests how to write and evaluate a measurable, time-bound patient outcome related to mobility, which is a nursing care planning concept under Basic Care and Comfort (Mobility-Immobility).

Question 17

Which of the following is a key aspect of promoting mobility in patients?

Accepted Answer

Answer reason: B. Encouraging regular physical activity within the patient's ability Mobilization helps maintain muscle strength, joint range of motion, cardiopulmonary function, and bowel/bladder function while reducing risks such as pressure injuries, atelectasis, venous thromboembolism, and deconditioning. The safe approach is individualized activity that matches tolerance, with gradual progression and appropriate supports. The other options promote immobility or unnecessary restriction, which increases complications and delays recovery.
Category reason: This question tests a nursing care action to maintain function and prevent immobility complications, which falls under Mobility-Immobility in Basic Care and Comfort.

Question 18

Which intervention promotes independence in a patient with limited mobility?

Accepted Answer

Answer reason: B. Encouraging the patient to do as much as possible This supports functional ability by maximizing the patient’s remaining strength and range of motion while preventing further deconditioning. Promoting self-care within safe limits improves confidence, preserves dignity, and can reduce complications of immobility. In contrast, doing everything for the patient, enforcing bed rest, or providing continuous assistance fosters dependence and accelerates loss of function.
Category reason: This question tests a nursing care intervention to promote patient independence and prevent complications related to limited mobility, which aligns with Mobility-Immobility under Basic Care and Comfort.

Question 19

In managing a patient with varicose veins, which of the following lifestyle changes would you NOT recommend for him/her?

Accepted Answer

Answer reason: Tight clothing can impede venous return from the lower extremities and worsen venous stasis, increasing discomfort and swelling in varicose veins. Recommended measures aim to promote circulation and reduce venous pressure, such as regular activity and compression therapy. Avoiding prolonged high-heel use can also support calf-muscle pumping and better venous return.
Category reason: This item asks which patient self-care/lifestyle intervention should be avoided to manage a circulatory condition, emphasizing nursing guidance on activity and measures that affect venous return, which fits Basic Care and Comfort (Mobility-Immobility).

Question 20

A nurse is assessing a client who has just been measured and fitted for crutches. The nurse determines that the client's crutches are fitted correctly if?

Accepted Answer

Answer reason: Proper crutch fitting requires a slight elbow flexion (about 20–30°) when the hands grasp the handgrips to allow effective weight-bearing through the hands and wrists while maintaining control and stability. Straight elbows reduce shock absorption and make safe gait patterns harder to perform. Weight-bearing through the axilla or having the crutch top even with the axilla increases risk of brachial plexus/vascular compression and indicates incorrect fitting; there should be a space of about 2 fingerbreadths between the axilla and the crutch pad.
Category reason: This question tests correct use and fitting of assistive devices (crutches) to support safe mobility and prevent complications, which is a nursing basic care/comfort mobility topic rather than foundational biomedical science.

Question 21

Common complication of prolonged bed rest is?

Accepted Answer

Answer reason: Immobility reduces pressure relief over bony prominences, leading to tissue ischemia, skin breakdown, and ulcer formation. Prolonged bed rest also contributes to moisture, friction, and shear forces that accelerate injury. Regular repositioning, skin assessment, pressure-redistribution surfaces, and adequate nutrition/hydration are key prevention measures.
Category reason: This question tests a nursing complication of immobility and the need for preventive care during bed rest, which fits Mobility-Immobility within Basic Care and Comfort.

Question 22

How should Nurse Michele guide a child who is blind to walk to the playroom?

Accepted Answer

Answer reason: This is the standard sighted-guide technique for safe ambulation with a visually impaired person because it allows the child to detect the nurse’s body movements and anticipate turns, steps, and stops. The nurse’s elbow provides a stable reference point while keeping the child in control of their own walking pace and balance. Walking ahead also helps the child avoid bumping into obstacles, while maintaining orientation in the hallway. The other approaches either provide insufficient guidance or can be less safe and less empowering.
Category reason: This question tests a nursing mobility/ambulation assistance technique to safely escort a visually impaired child, which aligns with Basic Care and Comfort—Mobility-Immobility.

Question 23

Scenario: An immobile patient has a Braden Score of 12. Q. What does this indicate?

Accepted Answer

Answer reason: A Braden Scale score of 12 falls in the moderate-risk range (typically 13–14 is moderate and 10–12 is high risk in some references, but many nursing teaching resources classify 12 as moderate-to-high; among the given options, moderate is the best fit). Immobility is a major contributor to pressure injury risk because it increases duration of pressure and reduces tissue perfusion. This score indicates the nurse should implement structured prevention measures such as regular repositioning, pressure redistribution surfaces, moisture management, and nutrition optimization. The other options underestimate risk (low/no risk) or overstate it without being the best match to the score provided.
Category reason: This item tests nursing interpretation of a skin-risk assessment tool and the related risk level in an immobile patient, which aligns with nursing care needs around immobility and prevention of complications.

Question 24

Position for postural drainage of lower lung lobes:

Accepted Answer

Answer reason: Lower lobe segments are best drained with the head lower than the chest so gravity helps move secretions from the bases toward larger airways for coughing/suctioning. Trendelenburg (or a modified head-down position) is classically used for postural drainage of lower lobes. Positions with the head elevated (e.g., Fowler’s) are more appropriate for upper lobes and would reduce gravitational drainage from the bases. Head-down positioning should be avoided or modified in patients with increased intracranial pressure, uncontrolled hypertension, aspiration risk, or severe reflux.
Category reason: This question tests a nursing intervention/positioning strategy (postural drainage) to promote airway clearance, which fits patient care under Physiological Integrity—Basic Care and Comfort (Mobility/positioning).

Question 25

A nurse prepares a patient for a sigmoidoscopy. Which position is correct for the procedure?

Accepted Answer

Answer reason: B. Sims' (left lateral) This position facilitates insertion and advancement of the sigmoidoscope by aligning the rectosigmoid angle and allowing the scope to follow the natural curvature of the colon. It also improves patient comfort and helps relax abdominal muscles, which can reduce procedural difficulty and discomfort. Compared with supine or prone positions, the left lateral Sims’ position provides safer access to the anus/rectum while maintaining airway protection and overall stability.
Category reason: This question tests the nurse’s role in preparing and positioning a patient for an invasive diagnostic procedure, which is a patient-care intervention under Basic Care and Comfort (Mobility-Immobility).

Question 26

After a hip replacement, which movement is contraindicated?

Accepted Answer

Answer reason: This position increases the risk of prosthetic hip dislocation, particularly after a posterior approach, by driving the femoral head posteriorly. Standard post–total hip arthroplasty precautions include avoiding excessive hip flexion, adduction past midline, and internal rotation during the early healing period. The other options describe generally encouraged or protective mobility/positioning practices used to maintain alignment and reduce dislocation risk.
Category reason: This item tests safe post-operative mobility and positioning precautions after joint replacement, which is a nursing care intervention topic under Mobility-Immobility.

Question 27

Which activity should a client with a recent laminectomy avoid?

Accepted Answer

Answer reason: After a laminectomy, prolonged sitting increases lumbar flexion and intradiscal pressure, which can worsen pain and stress the healing surgical site. Early postoperative care emphasizes frequent position changes and gradual activity to reduce stiffness and complications. Log-rolling is encouraged to maintain spinal alignment, and deep breathing/incentive spirometry are promoted to prevent atelectasis and postoperative pulmonary complications.
Category reason: This question asks about safe postoperative activity restrictions and mobility practices after spinal surgery, which is a patient-care intervention topic under Mobility-Immobility.

Question 28

A client has been diagnosed with carpal tunnel syndrome. What is the most common initial treatment?

Accepted Answer

Answer reason: B. Immobilization with a wrist splint Splinting (typically in a neutral wrist position, especially at night) reduces median nerve compression by limiting provocative flexion/extension and is the usual first-line conservative therapy. It is low risk and can improve symptoms without exposing the client to procedural complications. Steroid injections are generally considered when symptoms persist despite splinting or when faster short-term relief is needed. Surgery is reserved for severe cases (e.g., thenar weakness/atrophy, persistent numbness) or failure of conservative management.
Category reason: This question asks for the initial nursing/clinical management intervention for a common musculoskeletal/nerve entrapment condition, emphasizing conservative care measures rather than underlying anatomy or physiology.

Question 29

One of the complications of complete bed rest and immobility is which of the following?

Accepted Answer

Answer reason: Prolonged immobility predisposes clients to foot drop due to lack of active dorsiflexion and the weight of bedding pushing the feet downward, leading to a plantar-flexed position. Over time, sustained positioning and muscle imbalance cause shortening of the Achilles tendon and posterior calf muscles, resulting in a plantar-flexion contracture. This is a classic musculoskeletal complication of bed rest that nursing care prevents with positioning, splints/footboards, and range-of-motion exercises. Dorsiflexion is not a typical immobility complication; rather, it is the movement that becomes limited when foot drop develops.

Question 30

Complication that can be prevented by using foot rest ?

Accepted Answer

Answer reason: A foot rest (or footboard) supports the feet in neutral dorsiflexion and helps maintain proper alignment to prevent this contracture-related complication. This is a positioning and mobility-related preventive intervention used for patients on bed rest or in wheelchairs. By contrast, pressure-injury prevention is more dependent on frequent repositioning and pressure redistribution rather than a foot rest alone.

Question 31

Complication that can be prevented ny using foot rest ?

Accepted Answer

Answer reason: This prevents prolonged plantar flexion that leads to shortening of the Achilles tendon and weakening of dorsiflexor muscles, resulting in plantar-flexion contracture and the clinical problem of foot drop. Pressure injury prevention requires broader repositioning and skin care measures, not just a foot rest. Edema is primarily related to venous stasis and fluid balance and is better addressed with elevation, mobility, and compression when appropriate.

Question 32

Comfort Device used to prevent foot drop is ?

Accepted Answer

Answer reason: A foot board provides firm support against the soles, helping keep the feet aligned at 90 degrees and reducing risk of shortening of the Achilles tendon. A bed cradle mainly relieves pressure of linens on legs/feet but does not position the ankle to prevent contracture. Sand bags and pillows can be used for positioning and support but are less reliable for maintaining consistent dorsiflexion and may still allow plantar flexion.

Question 33

Best method to prevent foot drop in a client on bed rest is to use ?

Accepted Answer

Answer reason: A foot/ankle splint (or footboard-type orthosis) provides continuous positioning support and is specifically designed to prevent this deformity. Sandbags and blocks may help with general positioning but do not reliably keep the ankle at 90 degrees and can allow gradual plantar flexion. Cradles primarily keep bed linens off the feet to reduce pressure and are not effective for maintaining ankle alignment.

Question 34

The external rotation of the hip in the supine position, is prevented by ?

Accepted Answer

Answer reason: A trochanter roll is placed along the lateral thigh/hip to maintain neutral alignment by preventing the femur from externally rotating. This is a standard immobilization/positioning aid used in bedridden patients and post-op care to support proper body mechanics. A bed cradle protects linens from contacting the legs/feet and does not control hip rotation, while a knee rest primarily supports knee flexion rather than hip alignment.

Question 35

Which area of the body is adversely affected when the client is in the lateral position?

Accepted Answer

Answer reason: The auricle is a common pressure point because it has thin skin and limited subcutaneous padding over cartilage, making it vulnerable to pressure-related pain and skin breakdown. By contrast, the sacrum and coccyx are more adversely affected in the supine position, and the heels are classically high-risk in supine or semi-Fowler’s positions. Appropriate positioning uses pillows to offload pressure and keep the head/neck aligned, reducing focal pressure on the dependent ear.

Question 36

After lumbar laminectomy nurse should?

Accepted Answer

Answer reason: Using a draw sheet with the logroll technique turns the head, shoulders, hips, and legs as one unit, minimizing torsion on the lumbar spine and protecting the incision. Bending the knees during turning does not reliably prevent spinal rotation and may encourage flexion that increases strain. Peritonitis assessment is unrelated to a lumbar laminectomy, and coughing is not the key nursing action emphasized for protecting the surgical spine during repositioning.

Question 37

Rectal examination is done with a client in what position?

Accepted Answer

Answer reason: The left lateral (Sims) position flexes the hips and knees, relaxes the gluteal muscles, and provides optimal exposure for digital rectal examination and rectal procedures. It also reduces strain compared with supine-based positions and is commonly used in bedside nursing assessments. Lithotomy and dorsal recumbent are primarily used for pelvic/vaginal examinations, and supine provides poorer access and less comfort for rectal assessment.

Question 38

The external rotation of the hip in the supine position, is prevented by using ?

Accepted Answer

Answer reason: A trochanter roll placed along the lateral aspect of the thigh helps keep the femur from rolling outward, thereby preventing hip external rotation. This is a standard nursing intervention for clients with weakness, paralysis, or post-operative immobility to maintain functional joint position. A bed cradle primarily relieves pressure from bed linens, a bedboard supports mattress/positioning of the trunk, and a knee rest supports knee flexion rather than controlling hip rotation.

Question 39

A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the?

Accepted Answer

Answer reason: The three-point gait advances both crutches together, then the unaffected (weight-bearing) leg, while the injured leg remains flexed and does not accept weight. This pattern is specifically indicated for clients who must avoid weight-bearing on one lower extremity. A four-point gait maximizes stability but is used when weight-bearing is allowed on both legs, and swing-through is faster and less stable—undesirable in vertigo due to higher fall risk.

Question 40

A simple and cost-effective method for reducing the risk of hypostatic pneumonia in a bedridden patient is?

Accepted Answer

Answer reason: Regular repositioning improves ventilation-perfusion matching, enhances lung inflation, and facilitates mobilization/drainage of secretions, making it a low-cost preventive nursing intervention. It also reduces pressure-related complications while supporting overall pulmonary hygiene. Antibiotics are not used prophylactically for this risk due to resistance and lack of indication, and nebulization or humidified oxygen do not address the core issue of prolonged dependent stasis as effectively as turning/mobilization.

Question 41

The Braden Scale score of a client is 16 Most appropriate nursing action is..............?

Accepted Answer

Answer reason: A score of 16 indicates mild risk, so a scheduled repositioning plan is an appropriate primary nursing intervention to offload bony prominences and improve tissue perfusion. High Fowler’s can increase sacral pressure and shear and is not a prevention strategy unless clinically indicated for breathing. Moisturizer can help skin integrity but does not address the key mechanism of pressure-related ischemia as effectively as turning. Oxygen by mask is unrelated to the primary risk being assessed by the Braden Scale unless there is a separate respiratory problem.

Question 42

For a rectal examination, the patient can be directed to assume which of the following positions?

Accepted Answer

Answer reason: The left lateral (Sims) position is commonly used and allows relaxation of the gluteal muscles and easy access for digital rectal exam. The knee-chest (genupectoral) position can further straighten the rectal canal and may be used when greater exposure is needed. A horizontal recumbent/supine position can also be used in certain settings (e.g., limited mobility or concurrent abdominal/genitourinary assessment), so all listed positions are acceptable options depending on circumstances.

Question 43

Exercise has which of the following effects on clients with asthma, chronic bronchitis, and emphysema?

Accepted Answer

Answer reason: Regular, appropriately paced exercise is a core component of pulmonary rehabilitation because it improves overall conditioning and exercise tolerance even when lung function is chronically limited. Better aerobic conditioning decreases oxygen demand for a given activity and helps clients perform ADLs with less dyspnea and fatigue. This benefit applies broadly across asthma and COPD phenotypes when exercise is individualized and paired with symptom control strategies (e.g., warm-up, rescue inhaler use as prescribed). The statement that exercise worsens respiratory function is unsafe and inconsistent with evidence-based rehabilitation, while “reduces acute attacks” is not a reliable direct effect of exercise alone.

Question 44

A 71-yr-old obese patient has bilateral osteoarthritis. The nurse teaches the patient that the most beneficial measure to protect the joint is to?

Accepted Answer

Answer reason: Weight loss lowers compressive forces at the hips and knees with every step, improving function and reducing inflammation associated with adipose-derived cytokines. Assistive devices like walkers can reduce joint stress but do not address the primary driver here—excess body weight—and are typically adjuncts. Avoiding walking by using a wheelchair promotes deconditioning, worsens mobility, and can increase long-term disability rather than protect joint health.

Question 45

The nurse is caring for a school-aged child with Duchenne muscular dystrophy. Which would be the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: The most fitting nursing diagnosis targets the child’s limited tolerance for exertion and need for energy conservation, pacing, and mobility support. Pain is not typically a primary defining symptom in Duchenne muscular dystrophy compared with weakness and functional decline. Psychosocial concerns may occur, but the priority nursing focus in day-to-day care is managing decreased mobility and activity capacity safely.

Question 46

Which will help the school-aged child with muscular dystrophy stay active longer?

Accepted Answer

Answer reason: Swimming supports mobility and endurance with minimal joint stress and reduces the work of antigravity muscles due to buoyancy, allowing longer participation. Daily treadmill use can be overly fatiguing and may accelerate muscle breakdown in dystrophic muscles if intensity is not carefully limited. While rest periods and wheelchair use are important energy-conservation strategies, they do not directly promote ongoing activity in the way a safe, enjoyable low-impact exercise like swimming does.

Question 47

The nurse is reviewing the wall climbing exercise with a female who had a right radical mastectomy. Which of the following best describes the exercise?

Accepted Answer

Answer reason: The patient uses the fingers to “walk” up the wall to gradually elevate the arm, stopping when discomfort or incisional pulling is felt to avoid tissue stress and potential complications. This approach emphasizes controlled advancement rather than swinging, which can cause traction and increase pain or risk of injury. The other options describe ballistic arm swinging or an overly rigid positioning that does not reflect the hallmark gradual finger-walking method.

Question 48

Which of the following goals are realistic and appropriate when planning nursing care for patients with chronic degenerative neurological disease?

Accepted Answer

Answer reason: Maintaining ability in activities of daily living is realistic because targeted interventions (energy conservation, adaptive equipment, PT/OT, fall-prevention, and symptom management) can slow functional decline and preserve autonomy. Efforts to “stop disease progression” are generally not achievable through nursing actions, making that goal unrealistic. Planning for long-term care may become necessary later, but it is not the primary universal goal at the care-planning stage compared with supporting day-to-day function.

Question 49

The nurse is caring for a client who is experiencing left-sided weakness after a stroke. Where should the nurse stand to safely assist the client out of the bed to a chair?

Accepted Answer

Answer reason: With left-sided weakness, the right side is the stronger side and provides the best leverage for standing and controlled pivoting. Standing on and transferring toward the stronger side reduces the chance the weak leg will buckle and lowers fall risk during the sit-to-stand. Standing directly in front or behind limits effective guarding and body mechanics, and standing on the weak side increases instability during the pivot.

Question 50

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

Accepted Answer

Answer reason: Regular repositioning redistributes pressure, improves capillary blood flow, and reduces shear/friction forces, making it the most effective prevention measure for bedbound older adults. Massage over at-risk areas can increase tissue damage and is not recommended, especially if tissue is fragile or already erythematous. Lotions can help manage dryness but do not address the key mechanism of pressure-related ischemia. Moist heat to reddened areas can worsen inflammation and increase tissue injury rather than prevent breakdown.

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