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A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Hyperextension

Lateral flexion

Rotation

Flexion

Answer and Explanation

The Correct Answer is D

A. Hyperextension

Hyperextension refers to bending backward beyond the normal range.

B. Lateral flexion

Lateral flexion involves bending the neck to the side, ear toward shoulder.

C. Rotation

Rotation refers to turning the head side-to-side (e.g., shaking head “no”).

D. Flexion

Touching the chin to the chest is flexion of the neck-bending forward.

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Correct Answer is B

Explanation

A. Use metal clips to secure the wrap:

While metal clips are commonly provided with elastic bandages, they can easily become dislodged and may cause injury. Tape or self-adhesive wraps are often safer and more secure.

B. Adjust the pressure or tension as needed:

This allows for proper circulation and comfort. Bandages should be snug but not tight, and pressure may need to be adjusted for swelling or anatomical differences.

C. Overlap turns of the bandage equally:

This is a correct technique but not the most critical factor for effectiveness and safety. Equal overlapping helps provide uniform pressure, but adjusting tension as needed is more essential.

D. Face the patient and wrap from proximal to distal:

Wrapping should always go from distal to proximal to promote venous return and reduce edema. Wrapping proximal to distal is incorrect and can impair circulation.

A. Mr. Milby states his pain level is a 0/10 B. Head of bed is elevated 45 degrees C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion. D. all side rails on Mr. Milby's bed are down E. the knee dressing is loose and not adhering on all sides F. the machine is set to 45 degrees of flexion

Correct Answer is ["B","C","D","E"]

Explanation

A. Mr. Milby states his pain level is a 0/10

This indicates good pain control, which is expected and desired postoperatively.

B. Head of bed is elevated 45 degrees

Elevation this high may cause improper alignment and interfere with the machine’s function. Typically, HOB should be no more than 20-30 degrees during CPM use.

C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion

This could indicate excessive tension on the wound or early signs of complications like swelling or dehiscence.

D. All side rails on Mr. Milby’s bed are down

This is a safety hazard. At least one or two side rails should be up during machine use to prevent falls.

E. The knee dressing is loose and not adhering on all sides

Loose dressings may indicate poor wound protection and risk for infection or wound exposure.

F. The machine is set to 45 degrees of flexion

This is per the physician’s order and indicates proper settings.

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A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

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Naxlex Comprehensive Predictor Exams

A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:

Correct Answer is B

Explanation

Mr. Milby is a 69-year-old patient who underwent a total knee replacement 3 days ago. The orders fro the continuous passive motion (CPM) machine are to set it at 45 degrees of flexion and 0 degrees of extension for Mr. Milby. Select all the options that need to be reported to the responsible nurse.

Correct Answer is ["B","C","D","E"]

Explanation

Axillary crutches are commonly used for short-term needs. They are adjustable to a variety of heights and are easy to use. The following statements are true pertaining to crutches except

Please indicate whether the following statement is true or false. Decreased muscle mass, muscle tension, shortening of muscles, and loss of calcium are not effects of immobilization.

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