Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
A. "I will move your joints to the point of mild pain."
"I will move your joints to the point of mild pain":This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.
B. "I will repeat these movements 3 to 5 times."
"I will repeat these movements 3 to 5 times":This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.
C. "These movements will be performed once per day."
"These movements will be performed once per day":This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.
D. "I will move your joints quickly."
"I will move your joints quickly":This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.
This question is an excerpt from Nurse Dive's nursing test bank - RN FUNDAMENTALS 2023 PROCTORED EXAM. Take the full exam now
Full Explanation
A. "I will move your joints to the point of mild pain":
This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.
B. "I will repeat these movements 3 to 5 times":
This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.
C. "These movements will be performed once per day":
This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.
D. "I will move your joints quickly":
This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.
Similar Questions
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
A. Gown
After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.
B. Gloves
Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.
C. Mask
The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.
D. Eyewear
Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.
Full Explanation
A. Gown:
- After removing gloves, the gown should be taken off. The gown is considered the second most contaminated item. It is important to avoid contact with the outer surface of the gown while removing it.
B. Gloves:
- Gloves should be removed first because they are the most likely part of the PPE to be contaminated. Care should be taken to avoid touching the outside of the gloves, and they should be disposed of properly.
C. Mask:
- The mask is removed next. Care should be taken to handle the mask by the ties or ear loops without touching the front surface. Removing the mask last helps protect the nurse from potential respiratory droplets on the mask.
D. Eyewear/Face Shield:
- Eyewear or face shield is removed last. Similar to the other components, it should be handled carefully to prevent self-contamination. This step helps protect the eyes and face from any potential splashes or airborne particles.
A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?
A. Use trochanter rolls beside the client's legs.
Use trochanter rolls beside the client's legs:Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr.
Logroll the client every 4 hr:Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them.
Place the client's arms at their side when turning them:Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine.
Cross the client's ankles when lying supine:Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
Full Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
A. Exercise 1 hr before bedtime.
Exercise 1 hr before bedtime:While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day.
B. Drink a cup of hot cocoa before bedtime.
Drink a cup of hot cocoa before bedtime:While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime..
Eating a light carbohydrate snack before bedtimecan help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep.
D. Take a 30-min nap daily.
Take a 30-min nap daily:Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.
Full Explanation
A. Exercise 1 hr before bedtime:
While regular exercise is beneficial for overall health, exercising close to bedtime may actually interfere with sleep. It is better to exercise earlier in the day
B. Drink a cup of hot cocoa before bedtime:
While a warm beverage like hot cocoa may be soothing for some individuals, it contains caffeine, which can interfere with sleep. Caffeine consumption, especially close to bedtime, is generally discouraged for those experiencing insomnia.
C. Eat a light carbohydrate snack before bedtime: can help promote sleep. Carbohydrates increase the availability of tryptophan, an amino acid that contributes to the production of serotonin (a neurotransmitter associated with relaxation and sleep).However, the snack should be light and not too heavy to avoid discomfort or indigestion during sleep
.
D. Take a 30-min nap daily:
Taking a 30-minute nap daily may not be the most effective intervention for insomnia. Napping during the day can interfere with nighttime sleep, especially if it's taken too close to bedtime. Short naps earlier in the day are generally recommended if needed.