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 C

Explanation

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

A. Prior to inspecting the abdomen B. After checking for kidney tenderness C. After palpating the abdomen D. Prior to palpating the abdomen

Correct Answer is D

Explanation

A. Prior to inspecting the abdomen. The correct order of abdominal assessment is inspection → auscultation → percussion → palpation to avoid altering bowel sounds.

B. After checking for kidney tenderness. Assessing kidney tenderness is done through percussion, which should be performed after auscultation.

C. After palpating the abdomen. Palpation can stimulate bowel activity, potentially leading to false findings during auscultation.

D. Prior to palpating the abdomen. Auscultation should be done before palpation to prevent artificially altering bowel sounds.

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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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