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Fundamentals
Mobility/Immobility Ch 24 NCLEX Q's
| Question | Answer |
|---|---|
| Nursing is planning to help mobilize a patient with lower extremity weakness. Which of the following is/are the priority to ensure patient safety and prevent falls? Select all that apply a. Slide, push, or pull rather than lifting b. Lock wheels on bed, stretcher, or wheelchair c. Pivot body without twisting back d. Use mechanical aids | b. Lock wheels on bed, stretcher, or wheelchair---- d Use mechanical aids |
| A postoperative patient requests to be repositioned in bed. What should the nurse do first? a. Place feet in broad stance and flex knees b. Place one arm under the patients shoulders and one arm under the thighs c. Instruct patient to bend legs and put feet flat on the bed d. Elevate head of bed and place pillows under head | c. Instruct patient to bend legs and put feet flat on the bed |
| A bilateral below the knee amputation (BKA) patient needs assistance to his chair using a mechanical lift. Which of the following are appropriate assessments prior to transfer? (select all that apply) a. Comfort level b. Ability to follow directions c. Patients weight d. Limitations of a sling/life equipment | a. Comfort level---- b. Ability to follow directions---- c. Patients weight---- d. Limitations of a sling/life equipment---- |
| An elderly patient admitted with malnutrition has positioning aids ordered. Which aids would be most appropriate for this patient? a. Trapeze b. Bed Cradle c. Hand roll d. Elbow protector | d. Elbow protector |
| A patient is admitted with a cerebrovascular accident (CVA) and right-sided weakness. Which Nursing Diagnosis is most appropriate? a. Activity Intolerance b. Risk for Disuse Syndrome c. Risk for Self-Care Deficits d. Impaired Skin Integrity | c. Risk for Self-Care Deficits |
| A patient with a diabetic foot ulcer is placed on bed rest with affected foot elevated. Which rationale best supports this intervention? a. To reduce metabolic needs b. To reduce edema c. Risk for Self-Care Deficits d. Impaired Skin Integrity | b. To reduce edema |
| A one month-old is being examined at a well-child appointment. Which of the following would be normal findings? (select all that apply) a. Babinski reflex b. Limited hip flexion c. Foot drop d. Tonic nec | a. Babinski reflex---- d. Tonic neck |
| A 26 yrold patient is admitted from the recovery room and is identified as at risk for falls. Which of the following best describes the rationale for this nursing diagnosis? a. History of dizziness b. Depression c. Pain medication d. Confusion | c. Pain medication |
| A nursing assistant reports a blood pressure to be 70/49 with a heart rate of 126. What position would be appropriate for the nurse to use with this patient? a. Semi-Fowlers b. Sims c. Lithotomy d. Trendelenburg | d. Trendelenburg |
| A nurse is providing passive ROM to a patients left lower extremity when he encounters resistance in the ankle. What should the nurse do first? a. Assess the ankle for swelling b. Continue slow ROM activity to gently increase mobility c. Document findings in the patients chart d. Stop movement to prevent injury | d. Stop movement to prevent injury |
Created by:
luv4nursing
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