NCLEX Questions - Immobility, and Safe Movement Flashcards
A registered nurse is planning the client assignments for the day. Which is the most appropriate
assignment for the unlicensed assistive personnel (UAP)?
a. A client requiring crutch training
b. A client who is post-operative day 2 that needs ambulation
c. A client requiring assessment for passive range of motion tolerance
d. A client that weighs 300 pounds and needs to be transferred to the chair for the first time.
b. A client who is post-operative day 2 that needs ambulation
A nurse is doing active range of motion to a patient. She is seen pointing the toes of each foot
downward. Which word should the nurse chart to document exactly what done during range-of-
motion exercises?
a. Dorsiflexion
b. Dorsi-extension
c. Plantar flexion
d. Plantar extension
c. Plantar flexion
A nurse is transferring a patient from the bed to a wheelchair. Which should the nurse do to quickly
access this patient’s tolerance to the change in position?
a. Obtain a blood pressure
b. Determine if the patient feels dizzy
c. Monitor for bradycardia
d. Allow the patient time to adjust to the change in position
b. Determine if the patient feels dizzy
A patient has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication
of immobility is a concern to the nurse?
a. Contractures
b. Dehydration
c. Incontinence
d. Hypertension
a. Contractures
The nurse raises a patient’s arm forward and upward over the head during range-of-motion
exercises. Which word should the nurse use when documenting exactly what was done during this
range-of-motion exercise?
a. Hyperextension
b. Opposition
c. Supination
d. Flexion
d. Flexion
Which nursing action is most effective in relation to the concept “Immobility can lead to occlusion of
blood vessels in areas where bony prominences rest on a mattress?”
a. Encouraging the patient to breathe deeply 10 times per hour.
b. Performing range-of-motion exercises twice a day.
c. Placing a sheepskin pad under the sacrum.
d. Repositioning the patient every 2 hours.
d. Repositioning the patient every 2 hours.
To increase stability during client transfer, the
nurse increases the base of support by
performing which action?
a. Leaning slightly backward
b. Spacing the feet farther apart
c. Tensing the abdominal muscles
d. Bending the knees
b. Spacing the feet farther apart
Five minutes after the client’s first postoperative
exercise, the client’s vital signs have not yet
returned to baseline. Which is an appropriate
nursing diagnosis?
a. Activity Intolerance
b. Risk for Activity Intolerance
c. Impaired Physical Mobility
d. Risk for Disuse Syndrome
a. Activity Intolerance
Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching?
a. “Going up, the strong leg goes first, then the
weaker leg with both crutches.”
b. “Going down, the weaker leg goes first with both crutches, then the strong leg.”
c. “The weaker leg always goes first with both
crutches.”
d. “A cane or single crutch may be used instead of
both crutches if held on the weaker side.”
c. “The weaker leg always goes first with both
crutches.”
A client weighs 250 pounds and needs to be
transferred from the bed to a chair. Which
instruction by the nurse to the unlicensed
assistive personnel (UAP) is most appropriate?
a. “Using proper body mechanics will prevent you from injuring yourself.”
b. “You are physically fit and at lesser risk for injury when transferring the client.”
c. “Use the mechanical lift and another person to
transfer the client from the bed to the chair.”
d. “Use the back belt to avoid hurting your back.”
c. “Use the mechanical lift and another person
to transfer the client from the bed to the
chair.”
The client is ambulating for the first time after
surgery. The client tells the nurse, “I feel faint.”
Which is the best action by the nurse?
a. Find another nurse for help.
b. Return the client to her room as quickly as
possible.
c. Tell the client to take rapid, shallow breaths.
d. Assist the client to a nearby chair.
d. Assist the client to a nearby chair.
