Mobility
A nurse is educating a client recovering from hip surgery on the use of assistive devices. Which client statement indicates the need for further teaching?
A. “I should keep the cane on my stronger side.”
B. “I will go upstairs with my good leg first.”
C. “I should keep the crutch pads pressed against my armpits.”
D. “I will use my chair’s armrests to help push myself up.”
C.
Crutches should rest 2–3 finger widths below the axilla.
A nurse is reviewing intake and output records for a client recovering from abdominal surgery. The client has received 2,400 mL of fluid in the past 24 hours and voided 1,000 mL. What should the nurse do first?
A. Document the output as normal
B. Notify the healthcare provider
C. Assess the bladder for distention
D. Encourage the client to drink more fluids
C.
A large discrepancy between intake and output may indicate urinary retention. Assessing the bladder is the first step before notifying the provider.
Which client is at greatest risk for developing fecal impaction?
A. A middle-aged adult with lactose intolerance
B. An elderly bedridden client receiving opioids
C. A young adult experiencing anxiety before exams
D. A postoperative patient on a clear liquid diet
B.
Immobility and opioid use are strong contributors to fecal impaction.
The nurse is educating a patient on using a quad cane. Which of the following statements by the patient indicates correct understanding?
A. “I’ll hold the cane on my weak side.”
B. “I should keep my arm completely straight when using the cane.”
C. “I’ll move the cane forward at the same time as my weak leg.”
D. “The flat side of the quad base goes on the outside.”
C.
The cane and weak leg should move together for balance. Cane is held on the strong side.
What is ISOMETRIC, ISOTONIC, AND ISOKINETIC
ISOTONIC: SHORTENING OF THE MUSCLE WITH MOVEMENT
ISOMETRIC: SHORTENING OF THE MUSCLE WITHOUT MOVEMENT (YOGA POSE, OR PLANK)
ISOKINETIC: RESISTANCE ( BICYCLE, OR PUSHING AGAINST THE WALL
The nurse is assessing a client’s readiness for ambulation. The client has been immobile for a week. Which of the following findings requires the nurse to delay ambulation?
A. BP 110/70 mm Hg lying, 100/60 mm Hg standing
B. HR 88 bpm lying, 98 bpm standing
C. Dizziness upon sitting at the edge of bed
D. Muscle weakness in the left leg with equal hand grip strength
C.
This suggests possible orthostatic hypotension; ambulation should be delayed until safe.
Which step is essential when collecting a sterile urine sample from an indwelling catheter?
A. Collect urine from the collection bag port
B. Clean the catheter tubing with soap and water
C. Clamp the catheter tubing for no longer than 30 minutes
D. Collect at least 20 mL of urine for analysis
C.
This allows urine to collect in the tubing for a fresh sterile sample
A nurse is planning care for a postoperative client with limited mobility and a history of constipation. Which intervention has the highest priority to promote bowel function?
A. Offer a high-protein, low-fiber diet
B. Ambulate the client as early as possible
C. Provide a stool softener every 8 hours
D. Maintain strict fluid restriction
B.
Mobility stimulates peristalsis and is key in preventing constipation.
Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient? Select all that apply:*
A. The hand grips of the crutches are even with the mid-forearm.
B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees.
C. The patient has a 2-3 finger width distance between the axillae and crutch rest pad.
D. The patient places weight on the axillae rather than the hands while ambulating.
B, C
The answers are B and C. Properly fitted crutches should be a 2-3 finger width (about 1-1.5 inches) distance between the axillae (armpit area) and the crutch rest pads during ambulation. This prevents damaging the nerves that are located in the axillae during ambulation. In addition, when the patient grips the hand grips of the crutches the elbow should slightly bend at about 30 degrees
Plantar Flexion
pointing foot/toes toward the ground
Which of the following findings indicates proper ergonomics by a nurse assisting with a patient transfer? (Select all that apply)
A. Keeping the load close to their body
B. Twisting the torso while lifting
C. Using body weight to rock when pulling
D. Bending at the waist to lift
E. Using the legs for lifting power
A, C, E
A nurse is evaluating a client with complaints of leakage while sneezing or laughing. Which type of urinary incontinence should the nurse suspect?
A. Functional
B. Urge
C. Stress
D. Reflex
C.
Stress incontinence occurs when intra-abdominal pressure (laughing, sneezing) causes urine leakage.
A client reports black, tarry stools for the past 2 days. What should the nurse do first?
A. Document the finding as normal
B. Ask if the client takes iron supplements
C. Initiate a fecal impaction protocol
D. Administer an antidiarrheal medication
B.
Iron can cause black, tarry stools. Rule out benign causes before assuming GI bleed.
Your patient is using a cane for the first time. Before using the cane, you assess that the cane properly fits the patient. Which findings below demonstrate the cane properly fits the patient? Select all that apply:
A. The arm that is holding the cane is flexed at about a 40 degree angle.
B. The top of the cane is at the level of the greater trochanter.
C. When the patient dangles their arms, the top of the cane is even with the crease of the wrist closest to the hand.
D. There is a 1.5 inch gap between the top of the cane and the axillae.
B, C
The answers are B and C. Option B and C are correct because these are the two methods used to determine a proper fit for a cane
Dysuria
difficult or painful urination
Which of the following effects is most commonly associated with prolonged immobility?
A. Increased respiratory excursion
B. Hypocalcemia and increased bone density
C. Muscle atrophy and orthostatic hypotension
D. Increased peristalsis and diarrhea
C.
Immobility causes muscle wasting and cardiovascular deconditioning, leading to orthostatic hypotension.
A client with a spinal cord injury at T12 is experiencing overflow incontinence. What is the most likely cause of this condition?
A. Overactive detrusor muscle
B. Loss of sensation and bladder overdistension
C. Voluntary relaxation of the urethral sphincter
D. Increased pelvic floor muscle tone
B.
Overflow incontinence is often due to lack of sensation and retention, leading to overflow.
Which of the following clients is at greatest risk for developing chronic constipation?
A. A 21-year-old college student with a high-stress schedule
B. A 48-year-old female taking calcium supplements
C. A 75-year-old male who is bedbound after hip surgery
D. A 33-year-old postpartum woman with hemorrhoids
C.
Immobility, age, and surgery increase constipation risk.
Your patient is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches?
A. The patient moves both crutches forward and then moves both legs forward to the same point as the crutches.
B. The patient moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side).
C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together.
D. The patient moves both crutches and injured leg forward together, and then moves the non-injured leg forward.
C
The answer is C. The two-point gait is where the patient moves both the right crutch (injured side) and left foot (non-injured side) forward TOGETHER, and then moves the left crutch (non-injured side) and right foot (injured side) forward TOGETHER.
hand hygiene
peri care
urinate for 30mL into toilet
catch 3mL
finish voiding
peri care
hand hygiene
label and send to lab
Which ROM type is performed when a patient moves their limbs without assistance?
A. Passive
B. Active
C. Active-assistive
D. Resistive
B
In active ROM, the patient performs the movement without assistance.
A nurse is reviewing the output of four clients. Which client should be assessed for possible renal dysfunction?
A. Client A: 600 mL in 12 hours
B. Client B: 45 mL/hr
C. Client C: 300 mL in 12 hours
D. Client D: 1,200 mL in 24 hours
C.
This is only 25 mL/hr, indicating possible renal dysfunction
A nurse is instructing a client on collecting a stool sample for occult blood. Which client action indicates understanding?
A. “I will refrigerate the sample until I bring it in.”
B. “I will urinate into the same container before collecting stool.”
C. “I will avoid eating red meat 72 hours before testing.”
D. “I will use toilet paper to scoop the sample.”
C.
Red meat can cause false positives on fecal occult blood tests.
While using crutches the patient moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the:
A. Two-point gait
B. Swing-to-gait
C. Swing-through-gait
D. Three-point gait
C.
The answer is C. This description is known as the swing-through-gait. The key word to let you know it is the swing-through-gait is that the patient moves both legs PAST the placement of the crutches. It would have been the swing-to-gait if both legs moved forward to the same point as the crutch placement.
What does CAUTI mean?
Catheterization Associated Urinary Tract Infection