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

Repeat each exercise 10 times.

Increase flexion during a muscle spasm.

Support each extremity above and below the joint.

Move the joint just past the point of resistance.

Answer and Explanation

The Correct Answer is C

A. Repeat each exercise 10 times: Performing passive range of motion exercises 3 to 5 times per joint is usually enough to maintain joint flexibility and prevent stiffness. Repeating the exercises excessively may cause muscle fatigue or irritation, especially in immobile clients. The goal is to promote mobility without causing discomfort or harm.

B. Increase flexion during a muscle spasm: Forcing movement during a muscle spasm can increase pain and potentially cause injury to muscles or joints. The nurse should gently stop the exercise when a spasm occurs and allow the muscle to relax before continuing. Careful, slow movements help prevent exacerbation of muscle spasms.

C. Support each extremity above and below the joint: Supporting the extremity above and below the joint stabilizes the joint and surrounding tissues, reducing the risk of injury during passive movement. This technique also helps control the movement and minimizes discomfort for the client. Proper support is essential for safe and effective passive range of motion exercises.

D. Move the joint just past the point of resistance: Moving a joint beyond the point of resistance can cause tissue damage, pain, and joint injury. The nurse should stop movement at the point of resistance or the onset of discomfort, never forcing further motion. Respecting this limit preserves joint integrity and client safety.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

A. Prick the side of the client's finger: Pricking the side (lateral aspect) of the fingertip reduces discomfort and provides good blood flow compared to the center of the finger, making it the preferred site for capillary blood sampling.

B. Squeeze the client’s finger until a blood drop forms: Squeezing or "milking" the finger vigorously after the prick can cause hemolysis (rupture of red blood cells) and dilute the specimen with interstitial fluid. This can lead to inaccurate results.

C. Elevate the client’s hand above the level of the heart: Elevating the hand above heart level can reduce blood flow to the finger, making it harder to obtain an adequate sample. The hand should be positioned at or slightly below heart level.

D. Apply clean gloves: Wearing clean gloves protects both the client and nurse from exposure to bloodborne pathogens and maintains infection control standards.

E. Cleanse the client’s finger with an iodine swab: Iodine is not typically used for capillary puncture site cleansing due to potential skin irritation and interference with some tests. An alcohol swab is preferred for cleaning before puncture.

A. "I will keep the drainage bag below the level of my waist." B. "I will apply antiseptic ointment to the tip of my penis." C. "I will empty my drainage bag once a day." D. "I will clamp the tube when I go for a walk."

Correct Answer is A

Explanation

A. "I will keep the drainage bag below the level of my waist.": Keeping the drainage bag below the waist or bladder level is essential to prevent backflow of urine, which can lead to infection or bladder distention. This practice promotes proper drainage by gravity and helps reduce the risk of urinary tract infections.

B. "I will apply antiseptic ointment to the tip of my penis.": Applying antiseptic ointment is generally not recommended unless specifically prescribed by a healthcare provider. Routine use of ointments can irritate the urethral area or disrupt normal flora, potentially increasing infection risk.

C. "I will empty my drainage bag once a day.": Emptying the drainage bag only once daily is insufficient and increases the risk of urinary stasis and infection. The bag should be emptied regularly, at least every 8 hours or when it is two-thirds full, to maintain proper flow and reduce bacterial growth.

D. "I will clamp the tube when I go for a walk.": Clamping the catheter tubing can cause urine retention and increase the risk of bladder overdistention and infection. The tubing should remain open to allow continuous drainage regardless of activity level to ensure bladder emptying and prevent complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I feel worn out and don't have the energy to fight this disease. Am I dying?" Which of the following responses should the nurse make?

A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

A nurse is assisting with the care of a client in a medical-surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is most at risk of developing dropdown and dropdown. ​​​​​​

A nurse in an outpatient surgical center is assisting in the care of a client. Exhibits Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?