RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
A nurse notes that a client has ineffective coughing and deep breathing
kyphosis and generalized muscle
atrophy. Which problem is a priority Explanation:
when the nurse develops a nursing In kyphosis, the thoracic spine bends forward with
plan of care? convexity of the curve in a posterior direction, making
effective coughing and deep breathing difficult.
Although the client may develop other problems
because respiratory status deteriorates when
pulmonary secretions are not adequately cleared
from airways, ineffective coughing and deep
breathing should receive priority attention.
After surgery and insertion of a total joint dislocation.
hip prosthesis, a client develops
severe sudden pain and an inability to Explanation:
move the extremity. The nurse The joint has dislocated when the client with a total
interprets these findings as indicating: joint prosthesis develops severe sudden pain and an
inability to move the extremity. Clinical manifestations
of an infection would include inflammation, redness,
erythema, and possibly drainage and separation of
the wound. Bleeding could be external (e.g., blood
visible from the wound or on the dressing) or internal
and manifested by signs of shock (e.g., pallor,
coolness, hypotension, tachycardia). The seepage of
glue into soft tissue would have occurred in the
operating room, when the glue is still in the liquid
form. The glue dries into the hard, fixed form before
the wound is closed.
Four days after surgery for internal • back and head that are high
fixation of a C3-C4 fracture, a nurse is • seat that is lower than normal
moving a client from the bed to the • chair controlled by the client's breath
wheelchair. The nurse is checking the
wheelchair for correct features for this Explanation:
client. Which features of the The client with a C3-C4 fracture has neck control but
wheelchair are appropriate for the may tire easily using sore muscles around the
needs of this client? incision area to hold up the head. Therefore, the
head and neck of the wheelchair should be high. The
seat of the wheelchair should be lower than normal to
facilitate transfer from the bed to the wheelchair.
When a client can use the hands and arms to move
the wheelchair, the placement of the back to the
client's scapula is necessary. This client cannot use
the arms and will need an electric chair with breath,
chin, or voice control to manipulate movement of the
chair. A firm or hard cushion adds pressure to bony
prominences; the cushion should instead be padded
to reduce the risk of pressure ulcers.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
After undergoing surgery the previous Discuss the complications that the client's may
day for a total knee replacement, a experience if he doesn't cooperate with the care plan.
client states that he doesn't feel ready
to ambulate yet. What should the Explanation:
nurse do? The nurse should discuss the care plan and its
You selected: Discuss the rationale with the client. Calling the physician to
complications that the client's may report the client's noncompliance won't alter the
experience if he doesn't cooperate client's degree of participation and shouldn't be used
with the care plan. to force the client to comply. Doing nothing isn't
acceptable. Although the client does have the right to
make choices, it's the nurse's responsibility to provide
education to help the client make informed decisions.
Although the nurse should ultimately document the
client's refusal, she should first discuss the care plan
with the client.
When developing a long term care contractures.
plan for the client with multiple
sclerosis, the nurse should teach the Explanation:
client to prevent: Typical complications of multiple sclerosis include
contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward
the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not
associated with multiple sclerosis.
The nurse should assess which clients • client who is 45 years of age, in hospice with
for risk for falling? Select all that apply. terminal cancer, and receiving morphine every 2
hours
• client who is 62 years of age, recovering from
breast biopsy in outpatient surgery, and has a fear of
falling
• client who is 80 years of age and in a locked facility
for clients with cognitive impairment
• client who is 75 years of age and recovering at
home from hip replacement surgery on the left hip
Explanation:
Clients who are at risk for falling include the client
taking narcotics, the client with a known fear of
falling, the client with cognitive impairment, and the
client with gait problems. Age and setting are not
necessarily risks for fallings.
Which indicates that performing maintenance of joint mobility
passive range-of-motion (ROM)
exercises on an unconscious client Explanation:
has been successful? The goal of performing passive ROM exercises is to
maintain joint mobility. Active exercise is needed to
preserve bone and muscle mass. Passive ROM
movements do not prevent bone demineralization or
have a positive effect on the client's muscle tone.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
A public health nurse is providing an Daily range of motion exercises are required to
information session focusing on injury support joint mobility.
prevention for young children
diagnosed with juvenile arthritis. Of the Explanation:
information offered below, what should Daily range of motion exercises are required to help
be included in this session? children with juvenile arthritis strengthen their
muscles and use their joints to their full range of
motion. Children should be encouraged to participate
in as much of their own care as possible to keep their
joints fluid. Excessive exercise, as evidenced by
running, jumping, and so on, should be discouraged
because it puts an excessive amount of pressure on
the joints. The children should also remain active and
independent, but should not overexert themselves.
Home schooling is not required in this situation.
The nurse is caring for a child in provide frequent skin care.
Bryant's traction (see figure). The
nurse should: Explanation:
The traction is positioned correctly; the nurse should
provide frequent skin care to the back and shoulder
areas. The hips and buttocks should be lifted off the
bed to provide counter traction; the nurse should not
adjust the weights. The nurse should not place a
pillow under the buttocks as this would prevent
counter traction. The elastic wraps should remain on
the legs unless removal is prescribed by the health
care provider (HCP).
When the nurse is conducting a the client should not have her hip externally rotated
preoperative interview with a client when she is positioned for the procedure.
who is having a vaginal hysterectomy,
the client states that she forgot to tell Explanation:
her surgeon that she had a total hip The nurse should notify the surgery department and
replacement 3 years ago. The nurse document the past surgery in the medical record in
communicates this information to the the preoperative notes so that the client's hip is not
perioperative nurse because: externally rotated and the hip dislocated while she is
in the lithotomy position. The prosthesis should not
be a problem as long as the perioperative nurse
places the return electrode away from the prosthesis
site. The perioperative nurse will inform the rest of
the team, but the primary reason to inform the
perioperative nurse is related to safe positioning of
the client. The surgeon should enter this information
on the client's medical record at this time.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
When the client who has had a hip adduction of the hip joint.
replacement is lying on the side, the
nurse should place pillows or an Explanation:
abductor splint between the legs to After hip replacement surgery, the client should be
prevent: positioned on the nonoperative side with pillows or an
abductor splint between the legs to help prevent
adduction of the operative leg. This positioning
places the hip in proper alignment. Dislocation of the
hip can occur if the leg on the affected side is allowed
to adduct.
Flexion of the knees is not contraindicated.
Abduction of the legs is the correct position.
Placing a pillow between the legs will not result in
hyperextension of the knee. Hyperextension of the
knee is to be avoided in any case because it can
result in injury.
When assessing a client who reports a mechanism of injury.
back injury, it is critical for the nurse to
question the client about: Explanation:
The mechanism of injury is always the most critical
information to obtain from a client with a
musculoskeletal injury. In the event of a back injury,
the mechanism of injury provides the greatest clue as
to the extent of injury and the proper treatment plan.
The other questions are important but will not give
the critical information needed related to this specific
problem and injury.
A nurse prepares to transfer a client The nurse uses a rocking motion while helping the
from a bed to a chair. Which principle client to stand.
demonstrates safe body mechanics?
Explanation:
Rocking provides extra force when pushing or pulling.
The nurse should keep any weight as close to her
body as possible when lifting — not at arm's length.
The nurse should keep her knees slightly bent and
her feet spread apart to provide a wide base of
support. Keeping the knees straight and stiff and
bending at the waist and keeping the feet close
together aren't examples of safe body mechanics.
These positions could result in injury to the nurse or
to the client.
A nurse notes that a client has ineffective coughing and deep breathing
kyphosis and generalized muscle
atrophy. Which problem is a priority Explanation:
when the nurse develops a nursing In kyphosis, the thoracic spine bends forward with
plan of care? convexity of the curve in a posterior direction, making
effective coughing and deep breathing difficult.
Although the client may develop other problems
because respiratory status deteriorates when
pulmonary secretions are not adequately cleared
from airways, ineffective coughing and deep
breathing should receive priority attention.
After surgery and insertion of a total joint dislocation.
hip prosthesis, a client develops
severe sudden pain and an inability to Explanation:
move the extremity. The nurse The joint has dislocated when the client with a total
interprets these findings as indicating: joint prosthesis develops severe sudden pain and an
inability to move the extremity. Clinical manifestations
of an infection would include inflammation, redness,
erythema, and possibly drainage and separation of
the wound. Bleeding could be external (e.g., blood
visible from the wound or on the dressing) or internal
and manifested by signs of shock (e.g., pallor,
coolness, hypotension, tachycardia). The seepage of
glue into soft tissue would have occurred in the
operating room, when the glue is still in the liquid
form. The glue dries into the hard, fixed form before
the wound is closed.
Four days after surgery for internal • back and head that are high
fixation of a C3-C4 fracture, a nurse is • seat that is lower than normal
moving a client from the bed to the • chair controlled by the client's breath
wheelchair. The nurse is checking the
wheelchair for correct features for this Explanation:
client. Which features of the The client with a C3-C4 fracture has neck control but
wheelchair are appropriate for the may tire easily using sore muscles around the
needs of this client? incision area to hold up the head. Therefore, the
head and neck of the wheelchair should be high. The
seat of the wheelchair should be lower than normal to
facilitate transfer from the bed to the wheelchair.
When a client can use the hands and arms to move
the wheelchair, the placement of the back to the
client's scapula is necessary. This client cannot use
the arms and will need an electric chair with breath,
chin, or voice control to manipulate movement of the
chair. A firm or hard cushion adds pressure to bony
prominences; the cushion should instead be padded
to reduce the risk of pressure ulcers.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
After undergoing surgery the previous Discuss the complications that the client's may
day for a total knee replacement, a experience if he doesn't cooperate with the care plan.
client states that he doesn't feel ready
to ambulate yet. What should the Explanation:
nurse do? The nurse should discuss the care plan and its
You selected: Discuss the rationale with the client. Calling the physician to
complications that the client's may report the client's noncompliance won't alter the
experience if he doesn't cooperate client's degree of participation and shouldn't be used
with the care plan. to force the client to comply. Doing nothing isn't
acceptable. Although the client does have the right to
make choices, it's the nurse's responsibility to provide
education to help the client make informed decisions.
Although the nurse should ultimately document the
client's refusal, she should first discuss the care plan
with the client.
When developing a long term care contractures.
plan for the client with multiple
sclerosis, the nurse should teach the Explanation:
client to prevent: Typical complications of multiple sclerosis include
contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward
the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not
associated with multiple sclerosis.
The nurse should assess which clients • client who is 45 years of age, in hospice with
for risk for falling? Select all that apply. terminal cancer, and receiving morphine every 2
hours
• client who is 62 years of age, recovering from
breast biopsy in outpatient surgery, and has a fear of
falling
• client who is 80 years of age and in a locked facility
for clients with cognitive impairment
• client who is 75 years of age and recovering at
home from hip replacement surgery on the left hip
Explanation:
Clients who are at risk for falling include the client
taking narcotics, the client with a known fear of
falling, the client with cognitive impairment, and the
client with gait problems. Age and setting are not
necessarily risks for fallings.
Which indicates that performing maintenance of joint mobility
passive range-of-motion (ROM)
exercises on an unconscious client Explanation:
has been successful? The goal of performing passive ROM exercises is to
maintain joint mobility. Active exercise is needed to
preserve bone and muscle mass. Passive ROM
movements do not prevent bone demineralization or
have a positive effect on the client's muscle tone.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
A public health nurse is providing an Daily range of motion exercises are required to
information session focusing on injury support joint mobility.
prevention for young children
diagnosed with juvenile arthritis. Of the Explanation:
information offered below, what should Daily range of motion exercises are required to help
be included in this session? children with juvenile arthritis strengthen their
muscles and use their joints to their full range of
motion. Children should be encouraged to participate
in as much of their own care as possible to keep their
joints fluid. Excessive exercise, as evidenced by
running, jumping, and so on, should be discouraged
because it puts an excessive amount of pressure on
the joints. The children should also remain active and
independent, but should not overexert themselves.
Home schooling is not required in this situation.
The nurse is caring for a child in provide frequent skin care.
Bryant's traction (see figure). The
nurse should: Explanation:
The traction is positioned correctly; the nurse should
provide frequent skin care to the back and shoulder
areas. The hips and buttocks should be lifted off the
bed to provide counter traction; the nurse should not
adjust the weights. The nurse should not place a
pillow under the buttocks as this would prevent
counter traction. The elastic wraps should remain on
the legs unless removal is prescribed by the health
care provider (HCP).
When the nurse is conducting a the client should not have her hip externally rotated
preoperative interview with a client when she is positioned for the procedure.
who is having a vaginal hysterectomy,
the client states that she forgot to tell Explanation:
her surgeon that she had a total hip The nurse should notify the surgery department and
replacement 3 years ago. The nurse document the past surgery in the medical record in
communicates this information to the the preoperative notes so that the client's hip is not
perioperative nurse because: externally rotated and the hip dislocated while she is
in the lithotomy position. The prosthesis should not
be a problem as long as the perioperative nurse
places the return electrode away from the prosthesis
site. The perioperative nurse will inform the rest of
the team, but the primary reason to inform the
perioperative nurse is related to safe positioning of
the client. The surgeon should enter this information
on the client's medical record at this time.
, RN- MOBILITY NCLEX QUESTIONS WITH SOLUTIONS
When the client who has had a hip adduction of the hip joint.
replacement is lying on the side, the
nurse should place pillows or an Explanation:
abductor splint between the legs to After hip replacement surgery, the client should be
prevent: positioned on the nonoperative side with pillows or an
abductor splint between the legs to help prevent
adduction of the operative leg. This positioning
places the hip in proper alignment. Dislocation of the
hip can occur if the leg on the affected side is allowed
to adduct.
Flexion of the knees is not contraindicated.
Abduction of the legs is the correct position.
Placing a pillow between the legs will not result in
hyperextension of the knee. Hyperextension of the
knee is to be avoided in any case because it can
result in injury.
When assessing a client who reports a mechanism of injury.
back injury, it is critical for the nurse to
question the client about: Explanation:
The mechanism of injury is always the most critical
information to obtain from a client with a
musculoskeletal injury. In the event of a back injury,
the mechanism of injury provides the greatest clue as
to the extent of injury and the proper treatment plan.
The other questions are important but will not give
the critical information needed related to this specific
problem and injury.
A nurse prepares to transfer a client The nurse uses a rocking motion while helping the
from a bed to a chair. Which principle client to stand.
demonstrates safe body mechanics?
Explanation:
Rocking provides extra force when pushing or pulling.
The nurse should keep any weight as close to her
body as possible when lifting — not at arm's length.
The nurse should keep her knees slightly bent and
her feet spread apart to provide a wide base of
support. Keeping the knees straight and stiff and
bending at the waist and keeping the feet close
together aren't examples of safe body mechanics.
These positions could result in injury to the nurse or
to the client.
