A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

Abduction

External rotation

Internal rotation

Adduction

Answer and Explanation

The Correct Answer is A

A. Abduction:

Abduction refers to movement of a limb away from the midline of the body, such as raising the arm from the side outward and upward.

B. External rotation:

This refers to rotating a limb outward along its axis, not raising the arm overhead.

C. Internal rotation:

This refers to rotating the limb inward, which is not the action of lifting the arm above the head.

D. Adduction:

Adduction refers to moving a limb toward the midline, the opposite of abduction.

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Correct Answer is A

Explanation

A. False

A GI assessment should be done daily, especially in post-op clients or those on narcotics, which can slow bowel motility.

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 shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

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Naxlex Comprehensive Predictor Exams

Please indicate whether the following statement is true or false. A nurse working on the orthopedic floor understands that a gastrointestinal assessment should be done every three days.

Correct Answer is A

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

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