Question 1

The client with a lower leg amputation has edema, so the NA elevates the client’s residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client’s leg has been elevated?

Accepted Answer

Answer reason: Post-amputation positioning aims to prevent joint contractures that impair prosthesis use and long-term mobility. Elevating a residual limb directly on pillows tends to keep the knee in flexion, increasing risk for knee flexion contracture in a below-knee amputation. Elevation for edema control should be done by elevating the whole limb in neutral alignment (e.g., elevating the foot of the bed) rather than placing pillows under the stump. The nurse should correct the action and provide real-time coaching to the NA to prevent recurrence and protect functional outcomes.

Question 2

The immobile client is in a hospital bed at home. Which information should the home health nurse include when teaching family caregivers how to safely move and reposition the client?

Accepted Answer

Answer reason: “Before moving the client, raise the bed to waist level. After completing the move, return the bed to the lowest level.” Safe repositioning prioritizes caregiver body mechanics and patient fall prevention. Raising the bed to the caregiver’s waist height reduces trunk flexion and back strain during turning or boosting. Returning the bed to the lowest position afterward decreases the risk of the patient falling from an elevated surface. Other choices include unsafe mechanics (feet together while pulling) or positioning statements that do not directly address safe moving/repositioning practices.

Question 3

A client has just been admitted to the intensive care unit (ICU) and is chemically sedated and paralyzed. What is the best description of the precautions that need to be taken to prevent skin breakdown in this client?

Accepted Answer

Answer reason: Immobility from sedation/paralysis rapidly increases pressure-injury risk because constant pressure over bony prominences reduces capillary perfusion and causes tissue ischemia. Scheduled repositioning at least every 2 hours is a core prevention measure to offload pressure and improve microcirculation. When the client cannot tolerate full turns due to hemodynamic instability, using a 30-degree lateral tilt is an evidence-based alternative that decreases sacral/trochanter pressure while minimizing physiologic stress. Options claiming no precautions are needed are unsafe, and repositioning alone without addressing an alternative plan for instability is less complete than the best-practice description.

Question 4

A client has arrived in the preoperative area for knee surgery. The nurse asks the client to put an elastic stocking on the nonoperative leg. The client asks the nurse the purpose of the stockings. The nurse’s best response is?

Accepted Answer

Answer reason: Elastic (anti-embolism) stockings apply graduated compression to support venous return and reduce venous stasis, which is a major contributor to postoperative DVT risk, especially with lower-extremity surgery and immobility. By improving venous blood flow from the legs back to the central circulation, they lower the likelihood of clot formation in the deep veins. Maintaining core temperature is not the primary indication for these stockings, and joint mobility is not improved by compression garments. Referring to “arterial blood” is physiologically incorrect because the intended effect is on venous circulation.

Question 5

The nurse completes teaching the client with Cushing's disease. Which statement demonstrates that the client understands measures to prevent bone resorption from corticoid therapy?

Accepted Answer

Answer reason: " Glucocorticoids increase bone resorption and decrease bone formation, so prevention focuses on supporting bone density through mechanical loading and adequate calcium/vitamin D. Daily weight-bearing activity provides osteogenic stimulus that helps counter steroid-induced osteopenia/osteoporosis. A very high calcium target like 3000 mg/day is not standard teaching and can increase risk of adverse effects (e.g., nephrolithiasis) without addressing the key strategy. Limiting vitamin D is incorrect because vitamin D supports calcium absorption and bone health.

Question 6

The position of an unconscious patient should be changed at least every?

Accepted Answer

Answer reason: Regular repositioning at least every 2 hours is a standard preventive nursing intervention to offload pressure, improve perfusion, and reduce friction/shear when combined with proper turning technique. Longer intervals (4–8 hours) allow sustained pressure that markedly increases skin breakdown risk, especially in patients with poor nutrition, moisture, or impaired circulation. Turning schedules are also paired with skin assessment and support surfaces, but the baseline minimum interval commonly tested is every 2 hours.

Question 7

The nurse is teaching a client newly diagnosed with chronic venous insufficiency. Which of the following would be a priority for the nurse to include?

Accepted Answer

Answer reason: Chronic venous insufficiency is primarily managed by improving venous return and reducing venous hypertension to control edema and prevent venous ulcer formation. Graduated compression stockings are the cornerstone nonpharmacologic therapy because they directly counteract venous pooling and valve incompetence, making them the highest-yield teaching priority for symptom control and complication prevention. Correct technique and adherence (proper fit, applying in the morning, avoiding bunching that can create pressure points) determine effectiveness and safety. Leg elevation, exercise, and skin care are important adjuncts, but they do not reduce ambulatory venous hypertension as reliably as appropriately used compression.

Question 8

The home health nurse is visiting a client with an exacerbation of rheumatoid arthritis. To prevent deformities of the knee joints the nurse should?

Accepted Answer

Answer reason: Maintaining joint function in rheumatoid arthritis relies on balancing rest during acute inflammation with gentle, regular range-of-motion to prevent stiffness, contractures, and deformity. Promoting movement as tolerated supports muscle strength and preserves alignment without provoking excessive synovial irritation. Prolonged bed rest increases the risk of flexion contractures at the knees and accelerates deconditioning, which can worsen disability. Rigid positioning advice (e.g., sitting only in a recliner) can encourage sustained flexion and contribute to joint deformity rather than prevent it.

Question 9

The nurse is caring for a four-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?

Accepted Answer

Answer reason: Play-based activities that motivate the child to use upper extremities and coordinate movements align with physical and occupational therapy goals and increase participation. A video game can provide immediate feedback and repeated, graded movement practice in a developmentally appropriate way. In contrast, eye patching targets amblyopia/strabismus management and is not a general preparatory intervention for CP rehabilitation. Tongue-strengthening and auditory training may be appropriate for selected speech/hearing issues but are not the most broadly applicable intervention to prepare for rehab services.

Question 10

Your patient has significant mobility difficulties and his upper extremities are contracted. It takes several staff members to assist him out of bed, and he is becoming increasingly resistant to trying. Which of the following nursing actions will help him best avoid pressure injuries related to a lack of mobility?

Accepted Answer

Answer reason: Scheduled repositioning is the most direct nursing intervention to offload pressure, restore perfusion, and reduce shear forces in an immobile patient. A firm mattress does not provide targeted pressure redistribution and may increase interface pressure compared with specialized support surfaces. A low-protein diet would worsen skin integrity and impair wound prevention/healing, and compression devices primarily reduce venous thromboembolism risk rather than preventing pressure-related skin breakdown.

Question 11

How much room should be between the axilla and underarm pad of a crutch?

Accepted Answer

Answer reason: Maintaining about 2 finger-breadths (approximately 2 inches) between the axilla and the underarm pad reduces risk of brachial plexus compression and “crutch palsy.” This spacing also helps avoid axillary vessel compression that can cause pain, numbness, and weakness. A smaller gap (none or 1 inch) promotes leaning on the pad, while a much larger gap can compromise stability and safe gait mechanics.

Question 12

Which of the following is considered an iADL?

Accepted Answer

Answer reason: Budgeting specifically assesses the ability to handle financial management, which is a classic IADL domain. The other choices reflect basic self-care ADLs (e.g., oral hygiene, eating) or mobility, which evaluate more fundamental functional capacity rather than independent living skills. Identifying IADL impairment helps guide care planning for supports like home health services or guardianship when safety and autonomy are at risk.

Question 13

Which type of exercise is best for a patient with osteoporosis?

Accepted Answer

Answer reason: This option is a simple, accessible, low-impact weight-bearing exercise appropriate for many patients with osteoporosis. Non–weight-bearing options like swimming and bicycling improve cardiovascular fitness but provide less osteogenic loading to the skeleton. Seated resistance bands can be helpful for strengthening, but the question asks for the best overall exercise type for osteoporosis, where regular weight-bearing activity is the priority.

Question 14

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?

Accepted Answer

Answer reason: Parkinson disease commonly causes postural instability and a shuffling, festinating gait, increasing fall risk during ambulation. Nursing teaching should emphasize strategies that improve balance and reduce forward propulsion; keeping the arms close supports stability and helps maintain midline control. Leaning forward typically worsens festination and makes loss of balance more likely, so instructing avoidance of forward-leaning is not the best cue compared with actively promoting a stable posture. Pausing or hesitating between steps can aggravate freezing and disrupt gait rhythm, and resting specifically when tremors occur does not address the key ambulation hazard of impaired balance and gait control. The chosen instruction most directly targets safer gait mechanics and fall prevention during walking.

Question 15

The nurse is caring for a 3-month-old who was diagnosed with developmental dysplasia of the hip at birth and is wearing a harness. Which of the following interventions does the nurse anticipate?

Accepted Answer

Answer reason: Side-lying with a roll between the knees helps maintain hip abduction and avoids adduction that can worsen subluxation/dislocation. Surgical correction is not the expected initial step for a 3-month-old who is already being managed with a harness. Tight swaddling is contraindicated because it forces hip extension/adduction and can aggravate hip instability; additionally, harness care typically includes removing it for hygiene per provider instructions rather than leaving it on for bathing/diaper changes.

Question 16

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is experiencing increased shortness of breath. Which of the following interventions should the nurse implement first?

Accepted Answer

Answer reason: For acute worsening dyspnea, the immediate priority is to optimize ventilation using a rapid, low-risk intervention that improves chest expansion and reduces work of breathing. Upright positioning maximizes diaphragmatic excursion, improves lung volumes, and can quickly relieve air trapping in COPD. Pursed-lip breathing is helpful but typically follows positioning and coaching once the patient is placed to breathe more effectively. Increasing oxygen to 6 L/min is not the first step without assessment and may worsen hypercapnia in some COPD patients; sedatives can depress respiratory drive and are unsafe in acute respiratory distress.

Question 17

Which of the following patients is at greatest risk for developing pressure ulcers?

Accepted Answer

Answer reason: Being bed-confined creates sustained pressure over bony prominences, and incontinence adds maceration and skin breakdown from moisture and irritants. Advanced age and malignancy commonly correlate with frailty, weight loss, and protein-calorie malnutrition, reducing tissue tolerance and slowing repair. Compared with a patient who still gets out of bed with help, complete confinement plus incontinence and likely malnutrition represents the highest-risk clustering of factors.

Question 18

Which of the following positions would best aid breathing for a client with acute pulmonary edema?

Accepted Answer

Answer reason: Acute pulmonary edema impairs oxygenation by flooding alveoli and increasing work of breathing, so positioning should maximize lung expansion and reduce venous return to the heart. Upright high Fowler’s uses gravity to decrease preload, lowers pulmonary venous congestion, and allows the diaphragm to descend for better ventilation. This position also optimizes use of accessory muscles and improves V/Q matching compared with recumbent positions. Lying flat worsens orthopnea and increases pulmonary congestion, and semi-Fowler’s may help but is less effective than full upright positioning in severe respiratory distress.

Question 19

Which lifestyle modification helps in prolapse prevention?

Accepted Answer

Answer reason: Avoiding heavy lifting limits sudden strain on pelvic floor support structures. A high-fiber diet reduces constipation and straining during defecation, a common contributor to pelvic floor weakening. Controlling chronic cough decreases repetitive pressure spikes that can worsen descent, making the combined approach the most complete choice.

Question 20

A nurse is caring for a patient with a below-the-knee amputation (BKA). Which position helps to prevent hip contractures?

Accepted Answer

Answer reason: Positioning the patient prone places the hip in extension, providing a sustained stretch to hip flexors and reducing the risk of contracture after a BKA. This also encourages neutral alignment of the residual limb and counters the common tendency to keep the limb flexed for comfort. Fowler’s positions are common distractors because they may be comfortable for breathing and meals but they increase time spent in hip flexion and therefore increase contracture risk.

Question 21

The nurse writing a care plan for a client with dementia would include that the overall goal for nursing care is which of the following?

Accepted Answer

Answer reason: A global care-plan goal should be broad and long-term, emphasizing preservation of self-care abilities through cueing, routines, environmental supports, and appropriate assistance. The other choices are important interventions or specific physiologic needs, but they are narrower and do not capture the overarching rehabilitative/maintenance aim of dementia care. Reality reorientation can be ineffective or distressing in later stages, whereas function-focused care remains appropriate across stages.

Question 22

How should a nurse position a client diagnosed with an AMI to alleviate the symptom?

Accepted Answer

Answer reason: It also promotes lung expansion and improves oxygenation, addressing common AMI symptoms such as dyspnea and chest discomfort. Supine or prone positioning can worsen pulmonary congestion and increase cardiac workload by increasing venous return or limiting chest expansion. A left lateral position may be comfortable for some patients but does not as reliably optimize ventilation and hemodynamics as an upright posture in this setting.

Question 23

A client has just returned to a nursing unit after an above-knee amputation of the right leg. A nurse places the client in which position?

Accepted Answer

Answer reason: Keeping the residual limb flat in supine avoids sustained hip flexion that can occur with elevation on pillows, which increases risk of contracture and impaired gait training later. Prone positioning is often used later for short periods to stretch hip flexors, but it is not typically the immediate default right after returning from surgery due to comfort, monitoring needs, and airway/line management. Supporting the limb with pillows is a common error because it encourages flexion and abduction and can delay rehabilitation.

Question 24

The nurse is caring for a client who is 1 day post-operative for a total hip replacement. Which is the best position in which the nurse should place the client?

Accepted Answer

Answer reason: Positioning on the nonoperative side with the legs abducted (often with an abduction pillow) supports the new joint and reduces strain on the surgical site. Internal rotation is a classic malposition that increases dislocation risk, especially early post-op when soft tissues are healing. Lying directly on the operative side can increase pain and pressure on the incision and is not the preferred early postoperative position unless specifically permitted.

Question 25

A client on complete bedrest is at risk for disuse syndrome. The nurse should consider which client goal as appropriate?

Accepted Answer

Answer reason: Client goals should be patient-centered, measurable outcomes rather than nursing actions. Disuse syndrome from immobility leads to musculoskeletal complications such as joint stiffness and contractures, so preventing contractures is an appropriate, outcome-focused goal. The turning schedule and passive ROM are nursing interventions that support achieving the goal but are not themselves goals. “Shorter periods of immobility” is vague and less measurable than the absence of contractures.

Question 26

The nurse must apply an elastic bandage to support a client’s sprained ankle. Which action should the nurse take during this procedure?

Accepted Answer

Answer reason: Elastic bandage application should promote venous return and reduce edema while avoiding neurovascular compromise. Wrapping from distal to proximal supports upward fluid movement and helps prevent pooling and swelling below the wrap. Using only moderate tension provides support without creating a tourniquet effect that can cause pain, pallor, paresthesia, delayed capillary refill, or diminished distal pulses. A common error is applying consistently tight tension, which increases the risk of impaired circulation and tissue ischemia.

Question 27

The nurse is caring for a client with a diagnosis of aortic stenosis who has surgery scheduled in 2 weeks. The client reports episodes of angina and passing out recently at home. What would be the nurse’s best explanation about recommended activity at this time?

Accepted Answer

Answer reason: Symptomatic aortic stenosis creates a fixed cardiac output, so exertion can precipitate myocardial ischemia and syncope because the heart cannot increase forward flow to meet demand. Recent angina and fainting indicate high risk with increased activity, making conservative activity limitation the safest recommendation until definitive valve intervention. Avoiding activities that markedly raise heart rate, preload/afterload, or oxygen demand reduces the likelihood of collapse or sudden deterioration at home. Options encouraging scheduled walks or increasing activity underestimate the danger of exertional symptoms in severe aortic stenosis, where even moderate exertion can trigger hemodynamic compromise.

Question 28

An 80-year-old client has been admitted to the nursing unit with Parkinson’s disease. Which action by the nurse would be most appropriate in preventing disuse syndrome?

Accepted Answer

Answer reason: Weight-bearing and active exercises directly counter the deconditioning and musculoskeletal complications that occur when movement is limited, which is a common risk in Parkinson’s disease due to bradykinesia and rigidity. Turning every 2 hours primarily targets pressure injury prevention and does not adequately prevent global deconditioning. Nutrition and fluids support overall health but are not the primary intervention to prevent the functional decline of disuse.

Question 29

In assessing a client who has been immobilized because of illness, the nurse would most likely document the state of the client’s muscles as which of the following?

Accepted Answer

Answer reason: This is the expected assessment finding after prolonged bed rest or limited movement from illness. In contrast, hypertrophy occurs with increased workload/resistance training, not inactivity. “Flexible” and “hardened” are nonspecific descriptors and do not reflect the classic physiologic consequence of disuse.

Question 30

Nurse Sandra had just received a postoperative total hip replacement client from the recovery unit. Which is the best position in which she should place the client?

Accepted Answer

Answer reason: The priority after total hip arthroplasty is preventing prosthetic hip dislocation by maintaining proper alignment and avoiding hip adduction and internal rotation (and excessive flexion). Positioning on the nonoperative side reduces direct pressure and twisting forces on the operative hip while still allowing safe side-lying. Keeping the legs abducted (typically with an abduction pillow) maintains the femoral head seated in the acetabulum and prevents midline crossing. A common unsafe distractor is adduction, which increases the risk of posterior dislocation when combined with flexion or internal rotation.

Question 31

A nurse is preparing to care for a client who had undergone an above-knee amputation of the right leg. The nurse plans to allow which position for the client in the first 24 hours?

Accepted Answer

Answer reason: In the immediate postoperative period after an amputation, short-term elevation supports venous/lymphatic return and helps reduce edema at the stump, which can decrease pain and support early wound healing. Supporting the residual limb on pillows while supine is an appropriate position to allow during the first 24 hours for swelling control. Keeping the limb flat without any support is less effective for edema management early on. Prolonged prone or dependent positioning early is not the primary goal and can be uncomfortable or increase swelling, while Trendelenburg does not specifically address stump edema control and may create unnecessary physiologic stress.

Question 32

The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client?

Accepted Answer

Answer reason: Getting the client out of bed to a chair multiple times daily promotes strength, endurance, pulmonary expansion, and orthostatic tolerance, making progression to ambulation more successful. It also helps reduce risks for atelectasis, venous thromboembolism, constipation, and pressure injuries that can delay recovery. A wheelchair and family visits may support comfort and motivation but do not directly retrain functional mobility, and an overhead trapeze can increase unsafe hip movement and is not the primary strategy after hip repair.

Question 33

Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states, " If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?" What is the best response?

Accepted Answer

Answer reason:  Postoperative care prioritizes preventing immobility complications such as atelectasis, pneumonia, venous thromboembolism, and pressure injuries. Regular repositioning promotes lung expansion, circulation, and skin integrity while still allowing pain to be managed with splinting and analgesics. Encouraging “rest quietly” reinforces the patient’s misconception that staying still is beneficial and overlooks major risks. Deferring the decision until later fails to provide immediate, accurate teaching and undermines safe postoperative expectations.

Question 34

Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?

Accepted Answer

Answer reason: After an MI, patients may have periods of bed rest and reduced mobility, which increases clot risk in the lower extremities. Calf muscle pumping during walking and active leg movement promotes venous return and lowers the likelihood of thrombus formation. While mobility can also help with skin integrity and bowel motility, the most direct and prioritized physiologic purpose of frequent leg exercises and hallway ambulation in this context is preventing venous thrombosis.

Question 35

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities?

Accepted Answer

Answer reason: Post–myocardial infarction activity is advanced gradually to balance myocardial oxygen demand with healing and to prevent complications from immobility. Transfer from a coronary care unit to a telemetry medical unit generally indicates clinical stability appropriate for light activity such as toileting and basic self-care while continuing rhythm monitoring. Strict bed rest is typically unnecessary at this stage and increases risks such as deconditioning and thromboembolism. Unsupervised hallway ambulation and fully ad lib activity can provoke ischemia or dysrhythmias and should be introduced in a monitored, progressive, and often supervised manner based on tolerance.

Question 36

The nurse is working on a surgical floor. The nurse must log roll a male client following a?

Accepted Answer

Answer reason: Log-rolling is used to maintain strict spinal alignment and prevent rotation or flexion/extension of the vertebral column. After spine surgery such as a laminectomy, twisting can increase pain, disrupt the surgical site, and risk neurologic compromise, so turning the patient as a single unit is the safest technique. Thoracotomy and cystectomy patients may need splinting, pulmonary hygiene, and careful positioning, but they do not require strict “no spinal rotation” precautions as a primary rule. Hemorrhoidectomy mainly involves perineal pain control and bowel care rather than en bloc turning precautions.

Question 37

Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma?

Accepted Answer

Answer reason: Footdrop and plantarflexion contractures result from prolonged weakness/immobility and inadequate support of the ankle in neutral dorsiflexion. High-top sneakers provide external support that helps maintain proper ankle alignment during rest and early mobilization, reducing the tendency toward plantarflexion positioning. Low-dose heparin and sequential compression devices address venous thromboembolism prevention rather than joint positioning or muscle-tendon shortening. A physical therapy consult is helpful for rehabilitation planning, but the most direct nursing intervention listed to physically prevent footdrop/contracture at the bedside is providing supportive footwear to maintain dorsiflexion.

Question 38

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

Accepted Answer

Answer reason: Axillary lifting places traction on the brachial plexus and compresses neurovascular structures, increasing risk of nerve injury and shoulder damage, especially in a client with hemiplegia who has reduced protective muscle control and sensation. Safe repositioning uses a drawsheet/transfer device and broad hand placement on the torso/hips rather than pulling on the arm or placing hands in the axilla. Using a gait belt for ambulation support is appropriate, and praising efforts toward independence supports rehabilitation without adding physical risk. The unsafe handling technique is therefore the one that requires immediate nurse intervention to prevent injury.

Question 39

The client diagnosed with OA asks the clinic nurse “Is there anything I can take to help treat my disease?” Which is the nurse’s best response?

Accepted Answer

Answer reason: ” Osteoarthritis management emphasizes nonpharmacologic measures to improve function and relieve symptoms, with regular low-impact exercise as a core intervention. Activity helps maintain joint range of motion, strengthens periarticular muscles, and reduces stiffness, which directly addresses the client’s question about what can help the condition. OTC analgesics may reduce pain but do not address functional limitation as comprehensively and can carry GI/renal risks if used without guidance. Glucosamine/chondroitin have mixed evidence and are not the best general, evidence-based nursing response compared with exercise encouragement. Saying nothing helps is incorrect and undermines effective self-management.

Question 40

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching?

Accepted Answer

Answer reason: " Maintaining activity with appropriate, low-impact exercise is a key self-management strategy for chronic low back pain because it improves core strength, flexibility, and function while reducing deconditioning. Avoiding exercise tends to worsen stiffness and muscle weakness, increasing long-term pain and disability risk. Using heat/ice is a reasonable nonpharmacologic comfort measure for symptom control. Avoiding high heels and using supportive sleep surfaces can reduce lumbar strain, so those statements reflect correct teaching.

Question 41

When helping a stroke patients nurse should assist ...?

Accepted Answer

Answer reason: Providing assistance on the unaffected side allows the patient to bear weight and use the stronger leg/arm for support while the nurse guards and controls the gait belt effectively. This positioning also helps compensate for neglect/inattention to the affected side by keeping the stronger side available for handholds and corrective steps. Assisting on the weak side increases the chance that the patient will buckle, drag the foot, or be unable to regain balance during a misstep.

Question 42

The nurse is planning care for an infant with a diagnosis of an encephalocele located in the occipital area. Which item should the nurse use to assist with positioning the child to avoid pressure on the encephalocele?

Accepted Answer

Answer reason: A foam half-donut provides a recessed area so the occipital encephalocele is suspended without contact, reducing risk of rupture, CSF leak, bleeding, and infection. Sandbags are primarily for stabilization and can create focal pressure points against the lesion. Sheepskin and feather pillows may reduce friction or offer softness but do not reliably offload pressure from a discrete occipital protrusion, making them less safe and less specific for this need.

Question 43

The rehabilitation nurse caring for the young client with a T-12 SCI is developing the nursing care plan. Which priority intervention should the nurse implement?

Accepted Answer

Answer reason: Maintaining mobility is a priority early in spinal cord injury rehabilitation to prevent contractures, venous stasis, pressure injury risk, and loss of functional capacity. A T12 injury often preserves upper-extremity function and may allow varying degrees of lower-extremity function depending on completeness, making active ROM a high-yield, safety-focused intervention. Bowel and bladder programs are important, but they are typically scheduled routines and do not supersede immediate prevention of immobility complications. Vocational referral supports long-term psychosocial goals but is not the initial physiologic priority in the care plan.

Question 44

A nurse is reinforcing teaching with a parent of a child who has a sprained wrist. Which of the following interventions should the nurse instruct the parent to implement during the first 12 to 24 hr to minimize swelling?

Accepted Answer

Answer reason: Acute soft-tissue injuries are managed initially by reducing edema through improved venous and lymphatic return. Elevation above the heart uses gravity to decrease hydrostatic pressure and limit fluid accumulation in the injured tissues during the first 12–24 hours. In contrast, heat promotes vasodilation and can increase swelling early after injury, and active ROM may worsen pain and tissue stress in the acute phase. Compression can be helpful, but it must be snug (not loose) and carefully monitored for neurovascular compromise, making elevation the best single instruction here.

Question 45

A school-aged child with CF asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be most appropriate for the nurse to suggest?

Accepted Answer

Answer reason: Aerobic conditioning that promotes airway clearance and improves pulmonary endurance is generally encouraged for children with cystic fibrosis when tolerated. Water-based exercise provides sustained cardiovascular activity while supporting the chest and reducing impact stress, helping mobilize secretions through deeper breathing and coughing. It also tends to be easier to pace and maintain than stop-and-go field sports, allowing the child to regulate intensity and rest as needed. In contrast, more anaerobic or intermittently intense activities are less directly beneficial for secretion mobilization and may be harder to sustain for optimal respiratory conditioning.

Question 46

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

Accepted Answer

Answer reason: Elevating the affected arm on pillows supports drainage, reduces swelling, and helps prevent stiffness while avoiding dependent positioning. Semi-Fowler’s also supports respiratory expansion in the immediate postoperative period compared with lying flat, which is useful after anesthesia. Options where the arm is simply resting on the bed fail to provide elevation, and supine positioning is less optimal for postoperative ventilation and comfort.

Question 47

A nurse is teaching a client about crutch use following an ankle sprain. Which of the following actions by the client demonstrates an understanding of the teaching?

Accepted Answer

Answer reason: Slight elbow flexion (about 20–30°) allows the client to bear weight through the hands and wrists, absorb shock, and advance the crutches safely. Resting the axilla on the pads or leaning on the crutches can compress nerves and vessels, leading to numbness, weakness, or “crutch palsy.” Maintaining weight-bearing through the hand grips with correct elbow angle reflects safe, effective ambulation teaching.

Question 48

The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?

Accepted Answer

Answer reason: Slight elevation of the foot of the bed creates a gentle downhill slope toward the head, allowing body weight to resist the traction pull. This maintains alignment while minimizing skin movement against linens. Raising the head of the bed increases sliding toward the foot and worsens shear, and devices like a trapeze mainly assist repositioning rather than providing countertraction.

Question 49

A patient has just been diagnosed with osteoarthritis and is instructed to take an NSAID to manage pain and inflammation. Which of the following health care professionals should be consulted to help manage the patient's condition?

Accepted Answer

Answer reason: This professional can prescribe and teach individualized exercises, gait training, and activity modification to decrease joint stress and improve functional capacity. This also supports safe movement and helps prevent deconditioning and disability, which are key complications of chronic OA. A respiratory therapist is not relevant to OA, and while pain nursing or social work may provide supportive services, they do not directly address the core functional mobility impairment central to osteoarthritis care.

Question 50

A client who is postoperative total left knee replacement is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction?

Accepted Answer

Answer reason: After a left knee replacement, the left leg is the operative/weaker limb, so the client should step up first with the right leg, then bring the left leg up to the same step, with the cane used for balance/support (often moving with the operative leg, not leading ahead of the strong leg). Leading with the cane and then stepping up with the right leg suggests an unsafe sequence that can reduce stability and increase fall risk. The other actions are consistent with safe technique (cane in the opposite hand of the affected limb and generally facing forward while using the handrail).

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