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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Develops fatigue when assisting with morning hygiene care

Needs assistance raising her legs to put on socks

Performs active range-of-motion (ROM) exercises of all extremities

Demonstrates mild dyspnea when eating breakfast

Answer and Explanation

The Correct Answer is C

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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

Explanation

A. Loss of calcium from bone matrix

Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.

B. Stasis of respiratory secretions

Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.

C. Increased cardiac workload

Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.

D. Decreased circulation from pressure

Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.

E. Increased mental activity

Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.

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

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.

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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.

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

Explanation

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

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