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A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

Abducting the arm to a 90-degree angle from the side of the body

Adducting the arm so that is lies next to the client's side

Flexing the shoulder by raising the arm from a side position to a 180-degree angle

Circumducting the shoulder in a 180-degree half circle

Answer and Explanation

The Correct Answer is C

A. Abducting the arm to a 90-degree angle from the side of the body

This is only partial abduction; full ROM involves more than 90 degrees.

B. Adducting the arm so that it lies next to the client's side

Adduction is part of the range, but not a complete indicator of full shoulder ROM.

C. Flexing the shoulder by raising the arm from a side position to a 180-degree angle

This demonstrates full shoulder flexion, from rest to above the head.

D. Circumducting the shoulder in a 180-degree half circle

Circumduction is a circular movement, but a 180° half-circle isn’t a full demonstration of the shoulder’s capacity.

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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.

A. True B. Maybe C. Perhaps D. False

Correct Answer is A

Explanation

A. True

Immobility can lead to urinary stasis, which increases the risk of urinary tract infections (UTIs). Monitoring for urinary symptoms is essential to detect these complications early.

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A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

The nurse working with immobilized patients understands that monitoring for reports of pain with urination, changes in urination, and assessing fro frequency is essential in order to determine if an unwanted urinary problem is arising from her patient being immobile.

Correct Answer is A

Explanation

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