While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?

Limit ROM assessment to the lower extremities only.

Defer ROM assessment because of the respiratory rate.

Ask client to perform flexion and extension of arms 5 times.

Observe the client performing lateral flexion of the waist.

Answer and Explanation

The Correct Answer is B

A. Limit ROM assessment to the lower extremities only: Focusing only on the lower extremities does not fully address the concern. Any physical exertion could further strain the respiratory system when the client is already tachypneic and in distress.
B. Defer ROM assessment because of the respiratory rate: A respiratory rate of 30 breaths per minute indicates respiratory distress. Physical exertion, even mild, could worsen oxygenation issues. Protecting respiratory function is the priority, so the ROM assessment should be deferred until the client's condition stabilizes.
C. Ask client to perform flexion and extension of arms 5 times: Even minimal arm movements could increase oxygen demand and fatigue in a client already experiencing respiratory compromise, making this unsafe at the moment.
D. Observe the client performing lateral flexion of the waist: Lateral flexion involves significant muscular effort and could further tax respiratory function. It is not appropriate when the client is tachypneic and needs respiratory support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. When the pain interferes with activities of daily living: Waiting until pain affects daily functioning may cause unnecessary suffering and make pain harder to control. Postoperative pain management aims to address discomfort early before it escalates to a level that impairs normal activity.
B. As soon as the client begins to feel pain: Asking for pain medication at the onset of pain allows for more effective management. Treating pain early prevents the development of severe pain, enhances comfort, and often requires lower doses of medication compared to managing severe pain later.
C. When the client can no longer move comfortably: Delaying pain management until mobility is significantly impaired increases the risk of complications such as immobility, poor wound healing, and longer hospital stays. Early intervention is crucial for better outcomes.
D. Once the pain gets to a moderate level: Allowing pain to reach a moderate intensity before requesting medication can make it more difficult to control. It is better to preemptively manage pain to prevent escalation, leading to faster recovery and improved participation in rehabilitation activities.

A. Extend thumb at a right angle during gloving. B. Keep gloved hands in sight above waist level. C. Touch cuff fold only while applying second glove. D. Apply a mask once both hands are gloved.

Correct Answer is B

Explanation

A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.

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

While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is reviewing instructions about use of postoperative analgesia with a client before surgery. The PN should remind the client to ask for pain medication at which time?

Correct Answer is B

Explanation

While applying sterile gloves (open method), which action should the practical nurse (PN) take to ensure that surgical asepsis is maintained?

Correct Answer is B

Explanation

One week after beginning a new prescription for potassium chloride, a client tells the practical nurse (PN) that there is tingling and numbness in the feet and hands. Which action should the PN take?

The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned?

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

The practical nurse (PN) is providing care for a client with a history of a stroke and who has aphasia. The client is exhibiting restlessness, shallow respirations and is clenching teeth. Which problem should the PN assess further?

When initiating a 24 hour urine collection, which action should the practical nurse (PN) take?

When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?

An older adult client with a stage one sacral pressure wound is discharged with instructions for home care. Which information should the practical nurse reinforce with the client?