Question 1

Which statement is an example of a key element in a nursing care plan?

Accepted Answer

Answer reason: Ambulate 30 feet (9.1 m) with walker by discharge. A key element of a nursing care plan is an outcome/goal that is patient-centered and measurable, including a clear performance target and timeframe. This statement specifies the activity (ambulate), the measurable distance (30 feet), the assistance/device (with walker), and a time anchor (by discharge), making it evaluable. The other choices are interventions or provider-type orders that lack a measurable patient outcome focus. Measurable mobility goals also guide daily nursing actions and provide objective criteria to determine whether discharge readiness has been achieved.

Question 2

The nurse is providing instructions to a family who will be caring for a bed-bound client who is going home. The nurse determines that teaching was effective when the family members state the need to avoid the use of a?

Accepted Answer

Answer reason: Pressure-injury prevention focuses on distributing pressure evenly and avoiding devices that create localized high-pressure points and impaired perfusion. Donut/ring cushions concentrate pressure at the edges, which can reduce blood flow to surrounding tissue and increase the risk of skin breakdown, especially over bony prominences. In contrast, foam mattresses and gel/floatation surfaces are designed to redistribute pressure and reduce shear. A common mistake is thinking a donut “relieves” pressure, but it can worsen ischemia and delay healing.

Question 3

An unconscious client has left-sided paralysis. Which intervention should the nurse implement to best prevent foot drop?

Accepted Answer

Answer reason: A foot/ankle boot brace provides consistent dorsiflexion support and proper positioning when the client cannot reposition independently. The scheduled on/off regimen helps balance therapeutic positioning with prevention of pressure injury and skin breakdown. Range-of-motion exercises are beneficial but are less effective alone for maintaining continuous neutral alignment throughout prolonged periods of unconscious immobility.

Question 4

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of Paget’s disease and hypertension. Which of the following nursing diagnoses would be a priority plan of care for the client?

Accepted Answer

Answer reason: In a hospitalized client, mobility limitations create immediate risks such as falls, injury, and complications of immobility (e.g., constipation, skin breakdown, venous thromboembolism), making this the most urgent nursing focus. Hypertension management is important but does not outweigh the safety and complication risks tied to impaired mobility during the admission. Psychosocial diagnoses like social isolation or ineffective coping may be relevant, but they are typically addressed after stabilizing physiologic function and preventing mobility-related harm.

Question 5

Which statement by the client who recently had a cast applied indicates that the nurse’s teaching has been effective?

Accepted Answer

Answer reason: A newly applied plaster/fiberglass cast can feel warm because the setting (curing) process is exothermic, so transient warmth is expected and is not, by itself, a complication. Effective teaching distinguishes normal drying warmth from warning signs such as increasing pain, burning, foul odor, drainage, fever, or neurovascular compromise. Calling the provider for any heat alone reflects misunderstanding and would lead to unnecessary concern. Attributing early warmth to infection or stating the cast must be removed is inaccurate because infection would be suggested by systemic/local inflammatory signs, not normal curing heat.

Question 6

The nurse is concerned that a client recovering from a brain injury may be developing foot drop and contractures. What is the best intervention for the nurse to implement?

Accepted Answer

Answer reason: An ankle support (e.g., foot-up support/AFO-type positioning) keeps the foot in neutral, reduces risk of Achilles tendon shortening, and helps preserve safer gait mechanics during recovery. This is a direct, immediately implementable bedside intervention that targets the suspected complication. Anticoagulation or sequential compression devices address venous thromboembolism risk rather than preventing plantar-flexion contracture, and a therapy consult is helpful but not as immediate or specific as positioning/support to prevent worsening deformity.

Question 7

A client has developed a right torticollis with side bending to the right and rotation to the left. The nurse is aware that which exercises may assist in reduction of the torticollis?

Accepted Answer

Answer reason: With the head rotated to the left, corrective positioning/exercise uses rotation to the right to lengthen the tight muscle and rebalance neck range of motion. Rotating further to the left would reinforce the contracture and can worsen asymmetry. Flexion/extension are not the primary corrective planes for a rotation/side-bending torticollis pattern, so they are less targeted for reduction.

Question 8

The Milwaukee brace is commonly used in the treatment of scoliosis. Which position best describes the placement of the pressure rods?

Accepted Answer

Answer reason: The primary corrective pad/rod is positioned on the convex side so it can push the spine toward midline while counterforces stabilize above and below the curve. Placing pressure on the concave side would tend to worsen the deformity by further closing that side of the curve and does not provide effective derotation. Posterior-only placement is less accurate for addressing the main lateral convexity and rib prominence that bracing targets.

Question 9

Which statement by the parents of a child with crutches indicates understanding of how to safely walk down stairs?

Accepted Answer

Answer reason: Descending stairs with crutches follows the safety principle “down with the bad,” meaning the assistive device and injured/weak limb move down first to maintain a stable base of support. Placing both crutches onto the lower step first allows the child to transfer weight through the arms and crutches before the injured leg moves. Then the affected leg goes down, followed by the strong leg, which provides controlled support and prevents sudden loading or loss of balance. Saying to advance the strong leg first reflects the rule for going up stairs (“up with the good”) and increases fall risk when descending.

Question 10

A client had an appendectomy 24 hours ago. Which nursing goal is appropriate for this client?

Accepted Answer

Answer reason: Early ambulation within 24 hours after uncomplicated abdominal surgery is a key nursing goal to reduce postoperative complications such as atelectasis, venous thromboembolism, constipation, and ileus. Walking in the hallway is a realistic, measurable short-term functional milestone that reflects progressive mobility and recovery of activity tolerance. Physical therapy is not routinely required after a straightforward appendectomy, and expecting independent completion of all ADLs may be unrealistic this early due to pain and fatigue. Medication rationale teaching is important, but it is not the priority functional recovery goal for the first postoperative day compared with safely increasing mobility.

Question 11

The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?

Accepted Answer

Answer reason: Lowering the head of bed to under 30 degrees reduces sliding and therefore decreases shear on the sacrum and surrounding tissues. Padding and alternating-pressure surfaces primarily address pressure reduction rather than the sliding mechanism that creates shear. A lift device can reduce friction during repositioning, but controlling bed angle is the most direct, ongoing intervention to minimize shear forces in bed.

Question 12

The nurse, caring for the client who had bilateral THRs 2 days ago, determines that the client will need a referral to manage exercises and stairs when at home. The nurse should plan to initiate a referral with which interdisciplinary team member?

Accepted Answer

Answer reason: The physical therapist is the team member who teaches and progresses therapeutic exercises, gait training with assistive devices, and stair negotiation specific to the client’s weight-bearing status and hip precautions. Occupational therapy focuses more on activities of daily living and adaptive equipment (e.g., dressing, bathing, toileting) rather than stairs and exercise prescription. Social work addresses discharge resources and services, and the provider manages medical orders but does not deliver the structured mobility/stair training.

Question 13

A nurse is providing care for a client with a leg cast. To help prevent foot drop, which action by the nurse would be the most appropriate?

Accepted Answer

Answer reason: Positioning the foot at about 90 degrees provides this neutral dorsiflexion and reduces risk of contracture while the limb is immobilized in a cast. Forty-five degrees of flexion still allows significant plantar flexion and does not adequately protect against equinus positioning. Bed rest and warmth measures do not address joint positioning or muscle imbalance that leads to foot drop.

Question 14

A client has attended the sports medicine clinic to learn ways to prevent the risk of experiencing a sports-related injury. Which activity indicates that the client understands how to prevent sports-related injury?

Accepted Answer

Answer reason: A proper warm-up reduces stiffness and improves neuromuscular coordination, which lowers the risk of strains and sprains during activity. Strength training helps long-term resilience but does not immediately prepare tissues for a specific session’s demands. Moderate intensity and pacing can reduce overuse or fatigue-related injury, but they do not address the key pre-activity preparation that most directly prevents acute injuries at the start of exercise.

Question 15

The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?

Accepted Answer

Answer reason: About 20–30 degrees of elbow flexion indicates the walker is at an appropriate height, improving stability and reducing fall risk. Leaning over the front bar reflects poor posture and shifts the center of gravity forward, increasing the chance of losing balance. Lifting the walker off the floor is discouraged because it decreases stability and can create a trip hazard, and four wheels are not required and may be less appropriate when maximal stability is needed after surgery.

Question 16

The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which intervention should be included in the nursing care plan?

Accepted Answer

Answer reason: After a CVA, impaired motor control and altered sensation increase risk for shoulder subluxation, contractures, and dependent edema on the affected side, so proper positioning and support are key rehab nursing interventions. Supporting the affected upper extremity in neutral alignment helps prevent traction injury to the shoulder capsule and reduces discomfort while promoting functional recovery. Repositioning only once per shift is insufficient to prevent pressure injury and musculoskeletal complications in a client with limited mobility. Forcing the hand into a fist promotes flexion synergy and can worsen spasticity and contracture formation rather than maintaining functional positioning.

Question 17

To prevent circulatory impairment in an arm when applying an elasticbandage, which method is best?

Accepted Answer

Answer reason: Elastic bandages are designed to provide controlled compression, which requires gentle, even stretch to support tissues without obstructing arterial flow or venous return. Slight stretching with smooth, overlapping turns helps maintain consistent pressure along the limb and reduces the risk of tourniquet-like constriction. Wrapping it “loosely” can fail to provide support and may slip, bunch, and create localized pressure points that can impair circulation. Heavy pressure increases the risk of neurovascular compromise, and starting proximally rather than distally can worsen distal edema by trapping fluid.

Question 18

The nurse is caring for a bedridden older adult. What is the most important nursing intervention?

Accepted Answer

Answer reason: Preventing pressure injury in a bedridden older adult centers on consistent, individualized repositioning to reduce prolonged pressure and shear while accounting for tolerance, skin status, and comorbidities. A posted schedule operationalizes the plan for all caregivers and promotes adherence and continuity, which is critical to prevention. Repositioning “every 8 hours” is far too infrequent for pressure-injury prevention and would allow ischemia to develop. Sliding the client increases friction/shear risk, and vigorous massage over bony prominences can damage fragile tissue and worsen skin breakdown.

Question 19

The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching?

Accepted Answer

Answer reason: Wrist splints for carpal tunnel are used to keep the wrist in neutral and decrease median nerve compression while also protecting skin and circulation. Periodically removing the splint allows skin assessment, hygiene, and range-of-motion exercises to reduce stiffness and prevent pressure injury or neurovascular compromise. Leaving it on during bathing increases moisture and skin breakdown risk, and wearing it as tight as tolerated can worsen swelling and impair circulation. Using it only during finger-stressing work is less effective because symptoms often worsen with sustained wrist flexion/extension and at night, so consistent use with scheduled breaks is safer and more therapeutic.

Question 20

The client, who is diagnosed with CA, tells the clinic nurse about the inability to ambulate and about staying on bedrest due to hip stiffness. In addition to teaching the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the IICP?

Accepted Answer

Answer reason: A physical therapist can assess gait and functional limits, provide individualized range-of-motion and strengthening exercises, teach safe ambulation/transfer techniques, and recommend assistive devices to reduce pain and improve function. This directly targets the client’s reported inability to ambulate and tendency toward bedrest, which increases risk for deconditioning and further loss of joint function. A social worker or community organization may help with resources and support, but they do not provide the skilled therapeutic exercise and mobility training needed to address the primary functional problem.

Question 21

A client is admitted to the emergency department with a foot fracture, and a brace is applied. The nurse determines that teaching about the brace has been effective when the client makes which statement?

Accepted Answer

Answer reason:  The core principle is that external braces used after a suspected or confirmed fracture primarily immobilize and support the injured area to reduce pain, prevent further tissue damage, and maintain alignment until definitive treatment. Describing the brace as functioning like a splint reflects correct understanding of stabilization. Allowing movement would undermine fracture protection and can worsen displacement and swelling. Infection prevention is not a direct function of a brace, and “direct contact” is not a therapeutic goal in fracture immobilization and could contribute to pressure injury or skin breakdown if misapplied.

Question 22

The nurse is caring for a 70-year-old client who has undergone a right total hip replacement. The nurse is aware that the client should be repositioned?

Accepted Answer

Answer reason: Post–total hip arthroplasty care prioritizes preventing pressure injury and pulmonary complications while also avoiding hip positions that increase dislocation risk. Turning at least every 1–2 hours is standard to reduce prolonged pressure and promote comfort and circulation in an older immobile client. Repositioning should be done from the unaffected side toward the back to avoid placing the operative (right) hip into potentially unsafe alignment and excessive stress early after surgery. Options with 4–6 hour intervals increase risk of skin breakdown, and turning onto the affected side is typically avoided unless specifically allowed and well-supported with abduction precautions.

Question 23

The nurse is evaluating a client on crutches using a three-point gait. Which assessment made by the nurse would indicate that the client is using the crutches appropriately?

Accepted Answer

Answer reason: Safe crutch use requires supporting body weight through the hands with elbows slightly flexed, while keeping the axillary pad from bearing weight. Axillary weight-bearing can compress the brachial plexus and vessels, causing pain, numbness, or “crutch palsy,” so it is an unsafe technique. In a three-point gait, the crutches and the affected/weak leg move together, and the client bears weight through the hands and the unaffected leg as allowed by the prescribed weight-bearing status. Therefore, hand/palm weight-bearing is the expected finding indicating correct technique.

Question 24

A nurse determines that a client with a fractured left femur understands the instructions for touch-down weight bearing when the client makes which statement?

Accepted Answer

Answer reason: Touch-down (toe-touch) weight bearing permits the foot to make contact with the floor primarily for balance while avoiding meaningful load through the injured extremity. Allowing the foot to touch without placing weight matches this goal and helps maintain gait stability with an assistive device. Placing 30%–50% body weight reflects partial weight bearing, not touch-down. Keeping the leg completely off the floor describes non–weight bearing, which is more restrictive than touch-down and would not reflect correct understanding of this specific order.

Question 25

The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse’s assessment supports the presence of foot drop?

Accepted Answer

Answer reason: Foot drop is a positioning deformity where the ankle rests in plantar flexion due to weakness of the dorsiflexor muscles and loss of normal support in an immobile patient. An inability to keep the foot at a 90-degree angle to the lower leg indicates the foot is falling into plantar flexion, consistent with foot drop. This finding is commonly seen when patients are supine for prolonged periods without splints or proper positioning. In contrast, inability to plantar flex suggests a different motor deficit rather than the classic resting posture associated with foot drop.

Question 26

The nurse is planning the care for a client diagnosed with Parkinson disease. Which goal would be appropriate for the client problem of “impaired mobility”?

Accepted Answer

Answer reason: A mobility goal should be specific, measurable, and focused on improving functional movement that is often limited by rigidity and bradykinesia in Parkinson disease. Being able to reposition in bed is a concrete, realistic short-term outcome that directly targets impaired mobility and reduces risk for complications such as pressure injuries and respiratory stasis. The ambulation frequency goal may be appropriate later but is more demanding and may not be immediately achievable depending on gait freezing and fall risk. Carrying out ADLs is broader and overlaps with self-care deficit rather than isolating mobility as the primary problem.

Question 27

A home health nurse is caring for a 4-year-old child diagnosed with juvenile rheumatoid arthritis (JRA). The mother tells the nurse she is concerned about the child’s posture. What is the most important information for the nurse to give the mother?

Accepted Answer

Answer reason: JRA increases risk of pain-related guarding and flexion postures that can progress to joint contractures and poor alignment. Scheduled prone positioning promotes hip and knee extension and helps counteract flexion deformities, supporting better posture and functional mobility. In contrast, soft mattresses and “fluffy” pillows encourage sinking and joint flexion, which can worsen malalignment and stiffness. Semireclining also reinforces flexed positions and does not provide the extension needed to prevent contractures.

Question 28

Which patient outcome or goal should a nurse identify for a client with the nursing diagnosis of risk for disuse syndrome?

Accepted Answer

Answer reason: Disuse syndrome results from prolonged inactivity and leads to predictable complications such as muscle atrophy, contractures, orthostatic hypotension, atelectasis, and skin breakdown. A well-written outcome should be client-centered, measurable, and directly aimed at preventing the cause—immobility—by increasing activity and reducing time inactive. This goal is specific enough to guide interventions like early ambulation, ROM exercises, and scheduled turning. In contrast, being “free of musculoskeletal complications” is less measurable and too narrow because disuse affects multiple body systems, not only the musculoskeletal system.

Question 29

A nurse is preparing to bathe a client who is hospitalized for emphysema. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Clients with emphysema have limited expiratory airflow and are prone to dyspnea with activity, so positioning that maximizes lung expansion is a key safety measure during basic care. Elevating the head of bed improves diaphragmatic descent and ventilation, helping reduce work of breathing while the client is being turned and washed. Discontinuing oxygen risks acute hypoxemia during exertion, and routine escalation of nasal cannula flow to 6 L/min is not indicated and can worsen CO2 retention in susceptible COPD patients. Lowering the head of bed can impair ventilation and increase dyspnea rather than improve oxygenation.

Question 30

A nurse is caring for a client after a total knee replacement. The extremity was placed in a continuous passive motion (CPM) machine. Which action is one of the nurse’s responsibilities?

Accepted Answer

Answer reason: CPM therapy after total knee arthroplasty is used to promote joint mobility, reduce stiffness, and support functional recovery while protecting the surgical site. Nursing responsibilities include ensuring the device settings progress gradually as prescribed and monitoring the patient’s comfort, pain, and neurovascular status to guide safe advancement. Increasing flexion in small daily increments as tolerated aligns with typical CPM protocols and helps prevent complications related to immobility. In contrast, arbitrarily changing extension or only checking settings once daily does not capture the ongoing assessment and titration needed during use.

Question 31

The nurse is teaching a class of unlicensed assistive personnel (UAP) about the importance of mobility and turning clients. A UAP ask the nurse how often a client who is confined to bed should be turned. What is the best response by the nurse?

Accepted Answer

Answer reason: Regular repositioning reduces prolonged pressure over bony prominences, improves tissue perfusion, and helps prevent pressure injuries in bedbound clients. The standard basic nursing guideline is to turn/reposition at least every 2 hours, and more frequently (such as every 1 hour) for higher-risk clients or when skin tolerance is reduced. Turning every 8 hours is too infrequent and substantially increases ischemic skin breakdown risk. Keeping a client on the back as much as possible concentrates pressure on the sacrum and heels, increasing risk rather than preventing it.

Question 32

The nurse is caring for a client with osteoarthritis who is refusing to perform independent care. What is the most important nursing intervention for this client?

Accepted Answer

Answer reason: Maintaining the highest possible level of function is a primary goal in osteoarthritis, because activity preserves joint mobility, muscle strength, and independence. Supporting self-care within pain limits promotes autonomy while still respecting real physical limitations and preventing overexertion. Doing all care for the client can worsen deconditioning and reinforce dependence. Withholding analgesia until tasks are completed is coercive and may increase pain-related avoidance rather than improving functional participation.

Question 33

The nurse provided teaching to the client with a herniated lumbar disk. The nurse determines further teaching is necessary when the client makes which statement?

Accepted Answer

Answer reason: " Proper body mechanics reduce lumbar disc pressure by keeping the spine in neutral alignment and using the hips and knees to lift. Bending at the waist increases flexion and intradiscal pressure, which can worsen nerve root compression and pain with a herniated lumbar disk. Clients should instead squat, keep the object close, and avoid twisting during lifts. The other statements reflect appropriate teaching: core/back-strengthening exercises, weight control to reduce spinal load, and fiber/fluids to prevent constipation and straining that can aggravate back pain.

Question 34

The nurse is preparing a client for discharge. Which one of the following discharge instructions should be included when teaching the client how to prevent back injury?

Accepted Answer

Answer reason: Back-injury prevention teaching centers on minimizing spinal torque and reducing lever arm forces during daily activities. Holding objects close to the body keeps the load near the center of gravity, decreasing stress on the lumbar spine compared with carrying items at arm’s length. Side-lying sleep (often with a pillow between the knees) supports more neutral spinal alignment and can reduce strain compared with positions that increase lumbar lordosis. Options that include carrying objects at arm’s length increase the moment arm and substantially raise the risk of back strain even with lighter loads.

Question 35

The nurse is conducting a weekly support group for clients diagnosed with asthma, chronic bronchitis, and emphysema. The topic of today's class is exercise. The nurse determines teaching is effective when the clients states that exercise?

Accepted Answer

Answer reason: Regular, appropriately paced exercise supports conditioning and increases efficiency of breathing by strengthening accessory and diaphragmatic muscle use, which helps clients with chronic respiratory disease tolerate activity better. Pulmonary rehabilitation emphasizes graded aerobic activity and breathing techniques to reduce dyspnea on exertion and improve functional status rather than avoiding activity. While cardiovascular fitness can improve too, the key disease-specific teaching point is improved ventilatory muscle endurance/strength and activity tolerance. Exercise does not reliably prevent acute exacerbations/attacks by itself, and blanket discouragement would promote deconditioning and worsen outcomes.

Question 36

A nurse is talking with a 12-year-old boy and his parents about his osteogenesis imperfecta. The client tells the nurse he likes to swim. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Osteogenesis imperfecta causes bone fragility, so activity planning aims to improve strength and function while minimizing fracture risk. Swimming is a low-impact exercise that supports conditioning, but it does not provide the mechanical loading needed to promote bone mass and strengthen the musculoskeletal system. Adding carefully selected, supervised weight-bearing activity (as tolerated and individualized) supports bone health and functional mobility. Blanket restriction to only swimming or to no exercise is overly limiting and can worsen deconditioning, and the slip-risk response misses the broader teaching goal of safe, appropriate exercise selection with precautions rather than avoidance.

Question 37

A 14-year-old girl was recently fitted with a full back brace for scoliosis. Which response by the girl indicates she understands when she must wear the brace?

Accepted Answer

Answer reason: " Effective scoliosis bracing depends on near-continuous wear to apply consistent corrective forces during growth. Wearing it essentially full-time (removing briefly for hygiene per provider instructions) best supports curve control and slows progression. Taking it off for parties or for hours due to discomfort undermines treatment effectiveness and can allow the curve to worsen. The expected duration is typically months to years through growth, not just a couple of weeks, so that statement reflects misunderstanding.

Question 38

A client with chronic obstructive pulmonary disease (COPD) is being discharged from the hospital. The nurse provided teaching on medications, diet, and exercise. Which statement by the client indicates further teaching is necessary?

Accepted Answer

Answer reason: " Exercise for COPD should be paced and timed to minimize dyspnea and fatigue while supporting adequate energy and oxygenation. Doing activity before breakfast can occur when energy reserves are low and may increase shortness of breath and weakness, making it a less safe plan than exercising after rest and with appropriate nutrition/bronchodilator timing. Small, frequent meals reduce diaphragmatic pressure and work of breathing, and annual influenza vaccination lowers risk of respiratory infections. Early provider contact for cold symptoms is appropriate because minor infections can quickly precipitate an exacerbation.

Question 39

When assessing the client who is recovering from a radical hysterectomy with vulvectomy, the nurse notes lymphedema of the lower extremities. Which intervention should be implemented by the nurse?

Accepted Answer

Answer reason: Active range-of-motion and gentle lower-extremity exercises use the skeletal-muscle pump to move lymphatic fluid proximally and help reduce swelling while also lowering venous stasis risk. Raising the head of the bed does not specifically reduce leg edema and may not aid dependent fluid return. Increasing sodium intake would worsen fluid retention, and splinting would unnecessarily limit movement and can exacerbate swelling and immobility complications.

Question 40

The client has had recurrent episodes of low back pain. Which statement indicates that the client has incorporated positive lifestyle changes to decrease the incidence of future back problems?

Accepted Answer

Answer reason: " Preventing recurrent low back pain centers on using proper body mechanics that reduce spinal flexion/rotation and shear forces during activities. Avoiding bending and twisting during lifting/positioning directly addresses a major trigger for lumbar strain and disc aggravation. In contrast, shoe comfort alone does not target spinal mechanics, and an unrealistic exercise pattern does not reflect a sustainable prevention plan. Prolonged sitting for hours, even with legs elevated, can worsen stiffness and does not represent a preventive lifestyle change.

Question 41

A client is demonstrating to the nurse the understanding of touchdown weight bearing prior to discharge. Which of the following outcomes demonstrates that the nurse’s teaching is successful?

Accepted Answer

Answer reason: This protects healing bone or surgical repairs by minimizing load while still permitting a normalized gait pattern with assistive devices. Full weight bearing and 30%–50% weight bearing exceed the allowed load for this restriction and increase risk of displacement or delayed healing. Keeping the limb elevated at all times is not the defining feature of this weight-bearing status and would not be required for safe ambulation training.

Question 42

A 70-year-old male client is admitted to the medical-surgical unit with a fractured femur. The client is placed in Russell’s traction. The client asks the nurse to help him with back care. The most appropriate intervention by the nurse is?

Accepted Answer

Answer reason: Traction must remain continuous to maintain alignment and therapeutic pulling forces, so nursing care should be done without altering the setup. Using a trapeze allows the client to lift the torso for hygiene and skin care while preserving body alignment and keeping the traction line of pull intact. Supporting or removing weights disrupts traction and can cause loss of reduction, increased pain/spasm, and neurovascular compromise risk. Declining back care is inappropriate because skin integrity and comfort measures are essential in immobilized patients and can be safely provided with proper technique.

Question 43

A client preparing to transfer from the bed to a wheelchair complains of feeling light-headed and dizzy as he rises from a supine to a sitting position. Which action should the nurse take next?

Accepted Answer

Answer reason: This presentation is most consistent with orthostatic hypotension, so the immediate priority is to prevent a fall while allowing time for cardiovascular compensation. Keeping the client sitting with support and reassessing symptoms promotes safety and helps determine whether the dizziness resolves before attempting a transfer. Moving the client quickly to a wheelchair increases fall risk and could worsen hypotension. Leaving the client unattended while dangling is unsafe, and applying a safety vest is not the next step for an acute positional dizziness episode.

Question 44

A client with an above-the-knee amputation visits the orthopedic surgeon for a follow-up. Which comment to the nurse would indicate the client is properly caring for the stump and prosthetic leg?

Accepted Answer

Answer reason:  Safe prosthesis use and stump protection prioritize stability, fall prevention, and protecting the residual limb from shear/pressure injury during transfers. Applying the prosthesis before standing helps ensure a secure base of support immediately upon ambulation and reduces risk of losing balance while hopping or transferring without the device. Weekly skin inspection is inadequate because the residual limb should be checked at least daily for early signs of pressure areas. Antiseptic soap and only weekly socket cleaning can over-dry/irritate the skin and allow bacterial/odor buildup; routine gentle cleansing and more frequent liner/socket hygiene are typically needed.

Question 45

The client, who underwent a right mastectomy with lymph node dissection, is being admitted to a nursing unit from the PACU. When settling the client in bed, which action by the NA requires the nurse to intervene?

Accepted Answer

Answer reason: Positioning the arm dependent promotes venous/lymphatic pooling and can worsen edema and pain, so the arm should be supported and elevated per facility protocol while avoiding constrictive forces. Using the unaffected arm for blood pressure is appropriate, and posting a limb-alert to avoid venipuncture/IV access on the operative side is a standard protective measure. Confirming readiness for visitors supports psychosocial comfort and does not conflict with postoperative precautions.

Question 46

The nurse is assisting the client with arm and shoulder exercises on the client’s first postoperative day following a right—sided thoracotomy. The client reports pain with the exercises and wants to know why they must be performed. Which explanation should the nurse provide to the client?

Accepted Answer

Answer reason:  After thoracotomy, pain and guarding commonly reduce shoulder range of motion on the operative side, increasing risk of joint stiffness, contracture, and functional limitation. Early arm/shoulder exercises maintain mobility of the shoulder girdle and chest wall, supporting effective coughing and deep breathing by reducing splinting. This goal is functional preservation rather than improving perfusion or specifically expanding the opposite lung. Muscle removed during thoracotomy is not “rebuilt” by these immediate postoperative exercises; the priority is preventing immobility-related complications.

Question 47

The NA tells the nurse that the unit’s small- adult BP cuff cannot be found and that the client’s arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?

Accepted Answer

Answer reason: Accurate blood pressure measurement requires using the correct cuff size; an oversized cuff can falsely lower readings and lead to missed hypertension or inappropriate clinical decisions. The safest, most reliable action is to obtain the proper cuff from another unit so the measurement reflects the client’s true hemodynamic status. Estimating a correction factor is not evidence-based and introduces preventable error. Documenting inability to obtain a BP when an appropriate cuff can be obtained fails to meet basic assessment standards and delays care.

Question 48

Before ambulating the client for the first time, the nurse obtains the client’s BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?

Accepted Answer

Answer reason: A BP of 86/56 is hypotensive and could be artifact from an automatic cuff (wrong cuff size, movement, poor perfusion) or a true finding; confirming manually provides a more reliable baseline. Only after confirming should the nurse decide whether to hold ambulation and further assess symptoms or notify the provider. Proceeding to get the client out of bed risks orthostatic hypotension and falls, and chart review or additional assessment should not come before verifying the accuracy of the measurement driving the decision.

Question 49

The nurse is teaching the client prior to discharge following abdominal surgery. Which statement should the nurse include?

Accepted Answer

Answer reason:  Postoperative abdominal surgery teaching emphasizes gradual return to activity while protecting the incision from strain and avoiding heavy lifting early in recovery. A typical guideline is resuming work in several weeks depending on job demands, and encouraging progressive activity supports conditioning without excessive intra-abdominal pressure. Carrying 10-pound weights during daily walking is inappropriate shortly after abdominal surgery because it increases risk of dehiscence or hernia. The other options are either inaccurate/misfocused for standard discharge teaching or not a reliable, universally correct insurance guidance statement.

Question 50

The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?

Accepted Answer

Answer reason: An elevated toilet seat helps keep hip flexion within safe limits when toileting, and a walker provides stable, weight-bearing-appropriate ambulation early post-op. Placing the leg in adduction increases dislocation risk, making that intervention unsafe. Reinfusing drainage collected over 24 hours is generally outside typical nursing unit practice/parameters and is not the key safety priority compared with maintaining hip precautions during mobility.

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