A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Move body parts rapidly through the movements.

Support extremities above and below joints.

Continue moving body parts if muscle spasticity occurs.

Stretch the body part just beyond the existing range of motion.

Answer and Explanation

The Correct Answer is B

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

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Correct Answer is B

Explanation

A. Amber color. Normal urine color ranges from pale yellow to deep amber, depending on hydration. Amber urine alone is not abnormal.

B. White blood cells (WBC) 10. Normal WBC levels in urine should be ≤5 per high-power field (HPF). A count of 10 WBCs suggests infection or inflammation, such as a urinary tract infection (UTI).

C. pH 5.0. Normal urine pH ranges from 4.5 to 8.0, so a pH of 5.0 is within normal limits and does not require reporting.

D. Occasional casts. Occasional hyaline casts are normal, especially with dehydration or vigorous exercise. However, cellular casts (e.g., red blood cell casts) could indicate kidney disease.

A. Relief of urinary retention B. Convenience for the nursing staff or the client's family C. Routine acquisition of a urine specimen D. Measurement of residual urine after urination E. Presence of an open perineal wound

Correct Answer is ["A","D","E"]

Explanation

A. Relief of urinary retention. Urinary catheterization is indicated for clients who cannot void effectively, which can lead to bladder distension and complications.

B. Convenience for the nursing staff or the client's family. Catheterization should never be done for staff convenience due to the high risk of infection (CAUTI - catheter-associated urinary tract infection).

C. Routine acquisition of a urine specimen. Routine urine specimens should be obtained through clean-catch or midstream methods, unless a sterile sample is required for culture and sensitivity testing.

D. Measurement of residual urine after urination. Catheterization may be needed to measure post-void residual volume in cases of urinary retention.

E. Presence of an open perineal wound. A catheter can help prevent urine contamination of an open wound in the perineal area, reducing the risk of infection.

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A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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