Comprehensive Nursing Examination: Patient Ambulation, Assistive Devices, Crutch and Cane Gait Training, Walker Safety, Range-of-Motion Exercises, Orthostatic Hypotension Prevention, Fall Risk Reduction, Balance Strategy Training Programs, Sequential Comp

Comprehensive Nursing Examination: Patient Ambulation, Assistive Devices, Crutch and Cane Gait Training, Walker Safety, Range-of-Motion Exercises, Orthostatic Hypotension Prevention, Fall Risk Reduction, Balance Strategy Training Programs, Sequential Compression Device Management, Postoperative Mobility, Partial Weight Bearing, Pediatric and Geriatric Considerations, Neurovascular Assessment, Patient and Caregiver Education, Activity Tolerance, Dizziness and Safety Interventions, Axillary Crutch Fitting, Stair Navigation with Crutches, Joint Flexibility in ADLs, Delegation to Nursing Assistive Personnel, Pressure Injury Prevention, Functional Independence, DVT Prevention, Exercise Contraindications, Orthopedic Rehabilitation Exam Questions Verified and Complete with A+ Graded Rationales Latest Updated 2026 1. The nurse delegates helping the older patient ambulate with a walker without wheels to nursing assistive personnel (NAP). Which instructions should the nurse provide to the NAP? a.Show the patient how to slide the walker a few steps ahead. b.Check the patient for non-skid shoes before using the walker. c.Be sure that the patient places all weight on the front of the walker. d.Ensure that the patient is wearing soft slipper socks while walking. b.Check the patient for non-skid shoes before using the walker. The nurse instructs the NAP to check the patient for supportive, non-skid shoes to prevent injury to the patient's feet and provide sure footing while using the walker. The patient should be instructed to lift the walker and set it into place to advance. Sliding is not safe because it does not provide a stable foundation and is more likely to lead to patient falls. The patient should not place all weight on the front of the walker because this will cause the walker to tip. The patient should be instructed to place weight in the center of the walker for stability. Soft slipper socks do not provide adequate support for the ambulating patient and are more likely to lead to falls. 2. The nurse instructs the patient, who has right-sided weakness, to use the cane during ambulation and assesses the patient's use of the cane. Which assessment should the nurse address before the patient ambulates with the cane? a.The cane makes a tapping sound each time the patient touches it to the floor. b.The patient holds the cane in the unaffected hand for support. c.The patient holds the cane 10 to 15 cm (4 to 6 inches) to the side of the left foot. d.The patient ambulated 4 times with the cane in physical therapy. a.The cane makes a tapping sound each time the patient touches it to the floor. The cane should have a rubber tip on the end and should be silent when the rubber tip contacts the floor, indicating that the rubber is intact If the cane clicks each time it hits the floor, the rubber cannot effectively maintain the patient's stability. Using the cane on the unaffected (strong) side is proper technique for ambulating with a cane. Holding the cane 10 to 15 cm (4 to 6 inches) to the side of the unaffected (strong) foot is appropriate. Proper Fit: -top of cane should be at the level of the greater trochanter or crease of the wrist -15-30 degree the elbow should be flexed -Direct pt to place cane forward 15-25 cm (6-10 inches) even with affected leg Canes: -Straight: mild balance or strength impairment -Quad: unilateral weakness *Nurse stands on the patient's weak side for support, use gait belt The patient's history of cane use is valuable information for subsequent instruction and gives the nurse a basis for comparison. 3. A patient is being moved into a dangling position before ambulating. To decrease the chance of orthostatic hypotension, what activity can the patient do? a.Sit on the side of the bed for a minute before standing up. b.Take several deep breaths while moving into the dangling position. c.Push up from the bed into the dangling position on the side of the bed. d.Stretch all of the muscles in the body. a.Sit on the side of the bed for a minute before standing up. Sitting on the side of the bed stabilizes the redistribution of the blood during the position change. Deep breathing helps lung expansion but does not affect the change in the blood distribution during position changes. Pushing up from the side of the bed helps the patient transition to standing, but it doesn't prevent orthostatic hypotension. There are many muscles throughout the body that cannot be stretched voluntarily. 4. The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate, to prepare for discharge. Which is the best method for the nurse to assess a patient's ability to ambulate? a.Interview the patient's visitors. b.Talk with the patient about the distance to ambulate. c.Review the patient progress notes. d.Measure the distances ambulated. b.Talk with the patient about the distance to ambulate. Mutual goal setting between the nurse and the patient is a beginning point. Watching the patient ambulate is essential, but working with the patient is beneficial. Even if the patient's visitors are healthcare professionals, the nurse must assess the patient before taking action. Reviewing progress notes provides valuable baseline data for comparison to the nurse's assessment; however, the nurse ass