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The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat

respiratory alkalosis.

atelectasis.

hypostatic pneumonia.

low oxygen saturation.

Answer and Explanation

The Correct Answer is C

A. Respiratory alkalosis.

Respiratory alkalosis is caused by hyperventilation, not by immobility. Deep breathing won't target this issue.

B. Atelectasis.

While deep breathing can help prevent atelectasis (lung collapse), the primary concern in immobilized patients is hypostatic pneumonia.

C. Hypostatic pneumonia.

Deep breathing promotes lung expansion and mobilizes secretions, helping prevent hypostatic pneumonia, which results from stasis of secretions due to immobility.

D. Low oxygen saturation.

While deep breathing may improve oxygen saturation, the primary goal is to prevent atelectasis and pneumonia.

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Correct Answer is B

Explanation

A. Ask the client if she has been out of bed today:

This gives some insight into activity level but doesn't objectively measure strength.

B. Ask the client to push her legs and feet against the nurse's palms:

This provides a direct, physical assessment of the client's lower extremity strength, which is essential before ambulation.

C. Check the client's pedal pulses and feet for edema:

These assessments are related to circulation, not muscular strength.

D. Ask the client how strong she feels today:

This is subjective and may not reflect actual muscle strength or ability to ambulate safely.

A. Mr. Milby states his pain level is a 0/10 B. Head of bed is elevated 45 degrees C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion. D. all side rails on Mr. Milby's bed are down E. the knee dressing is loose and not adhering on all sides F. the machine is set to 45 degrees of flexion

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.

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The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is B

Explanation

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.

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

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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?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)