Question 1

The patient ambulates with two crutches, and the nurse notes that the patient's weight is resting on the axilla.Which intervention is best?
A) Document that the patient is using the crutches properly.
B) Encourage the patient to minimize the weight on the axilla.
C) Ensure the patient's crutches fit him or her properly.
D) Increase the layer of padding to the top of the crutches.

Accepted Answer

C

Question 2

The health care provider prescribes partial weight bearing of the left leg for the postoperative patient.Which instruction does the nurse include in patient teaching?
A) Prevent the left leg from touching the floor at all times.
B) Rest the left leg gently on the floor to stand with crutches.
C) Distribute weight equally to each leg while crutch walking.
D) Step with the left leg first to ascend the stairway with crutches.

Accepted Answer

Partial weight bearing means the patient can rest the left leg on the floor but should not put full weight on it, using crutches to support the rest of the weight.

Question 3

A patient's pulse has gone from 78 at rest to 98 after ambulating.What nursing action is indicated at this time?
A) Ask the health care provider to order a wheelchair for the patient.
B) Plan an adequate rest period before and after ambulating.
C) Sit the patient on the bed for 15 minutes before ambulating.
D) Increase the amount of range-of-motion exercises done daily.

Accepted Answer

An increase in pulse rate after ambulation is normal, but planning adequate rest periods can help manage the patient's cardiovascular response and prevent overexertion.

Question 4

The nurse teaches the patient's caregiver how to respond if the patient begins to fall while ambulating.Which instruction does the nurse provide to minimize potential injury to the patient and the caregiver?
A) Get the nearest chair and put it behind the patient.
B) Ease the patient to the side to protect his or her head.
C) Straighten your leg and help the patient slide to the floor.
D) Hold onto the gait belt and pull the patient close to you.

Accepted Answer

The nurse instructs the caregiver to straighten their leg and help the patient slide to the floor to minimize injury. This technique helps control the fall and reduces the risk of injury to both the patient and the caregiver.

Question 5

The nurse has assessed a patient using the Well's score and documented the score as an 8.What intervention by the nurse is most appropriate?
A) Document the findings in the patient's chart.
B) Collaborate with the provider on DVT prevention.
C) Inform the provider the patient is ready for more activity.
D) Consult with physical therapy for balance training.

Accepted Answer

A Well's score of 8 indicates a high probability of deep vein thrombosis (DVT), so the nurse should collaborate with the provider on DVT prevention measures.

Question 6

The patient is currently learning how to use crutches so there is minimal weight on the affected leg.Which type of crutch-walking technique will the nurse be reinforcing?
A) Two-point gait
B) Three-point gait
C) Swing-to gait
D) Swing-through gait

Accepted Answer

The three-point gait is used when the patient can bear weight on one leg but not the other, allowing minimal weight on the affected leg.

Question 7

Nursing assistive personnel (NAP) are working with patients performing range-of-motion exercises.Which activity can the nurse delegate to NAP?
A) Determine the patients' current pain level.
B) Assist stable patients with their range-of-motion exercises.
C) Force the joint motion gently a slight bit with each session.
D) Place socks on patients before exercising the lower extremities.

Accepted Answer

NAP can assist stable patients with range-of-motion exercises as it is within their scope of practice to help with basic care activities under the supervision of a nurse.

Question 8

The nurse is planning to perform range-of-motion exercises on a patient who has had a stroke and has mobility issues.Which of the following principles does the nurse follow?
A) Complete the exercises in a bottom-up approach.
B) Repeat each movement 8 times during the exercise period.
C) Always use gloves if there are skin lesions.
D) Complete the exercises in a head-to-toe sequence.

Accepted Answer

The head-to-toe sequence is a systematic approach that ensures all joints are exercised, promoting consistency and thoroughness in the range-of-motion exercises.

Question 9

The nurse instructs the patient how to incorporate range-of-motion exercises into activities of daily living (ADLs).With which of the patient's joints can the nurse perform the most movements for the ADLs?
A) Hip
B) Shoulder
C) Ankle
D) Wrist

Accepted Answer

The answer of The nurse instructs the patient how to...

Question 10

The nurse is instructing a patient with a right hip replacement to descend stairs by using crutches.Which does the nurse include in patient teaching?
A) Use the handrail on the right side.
B) Shift the weight to the left leg to begin.
C) Keep crutches very close to the hips.
D) Place the left leg on the stair below first.

Accepted Answer

When descending stairs with a right hip replacement, the patient should shift weight to the left leg to maintain stability and protect the healing hip.

Question 11

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 into the dangling position on the side of the bed.
D) Stretch all of the muscles in the body.

Accepted Answer

Sitting on the side of the bed for a minute before standing up allows the body to adjust to the change in position, helping to prevent orthostatic hypotension.

Question 12

The nurse is measuring vital signs when the patient, who is standing, reports dizziness.What is the nurse's priority intervention?
A) Call for immediate assistance.
B) Help the patient to lie on the floor.
C) Help the patient to a seated position.
D) Inform the patient that the dizziness will pass.

Accepted Answer

The priority intervention is to help the patient to a seated position to prevent falls and ensure safety.

Question 13

The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate.Which is the best method for the nurse to assess a patient's ability to ambulate?
A) Interview the patient's visitors.
B) Discuss ambulation goals.
C) Review the patient progress notes.
D) Measure the distances ambulated.

Accepted Answer

The answer of The nurse is preparing to increase the...

Question 14

The nurse teaches a patient who is alert and oriented to use a cane for left leg weakness.Which does the nurse include in patient teaching?
A) Use a firm grip to grasp the cane with the right hand.
B) Place the cane about 30.5 cm (12 inches) in front of the right leg.
C) Distribute weight evenly between the cane and the left leg.
D) Move the right leg forward first, the cane next, and left leg last.

Accepted Answer

The cane should be held in the hand opposite the weak leg, which is the right hand in this case, to provide support and balance.

Question 15

The nurse delegates helping the older patient ambulate with a walker without wheels to nursing assistive personnel (NAP).Which instructions does 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.

Accepted Answer

The nurse should instruct the NAP to check that the patient is wearing non-skid shoes to prevent slipping and ensure safety while using the walker.

Question 16

The nurse is explaining to a nursing student the importance of making sure the patient is wearing the ordered sequential compression devices (SCDs) when in bed.Which of the following statements indicate a good understanding of the purpose of SCDs by the student? (Select all that apply.)
A) Used to prevent DVTs.
B) Alright to walk while wearing.
C) Can be used if patient has a DVT.
D) Does not affect Virchow's triad.
E) Prevent venous stasis.

Accepted Answer

The answer of The nurse is explaining to a nursing...

Question 17

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 would 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 10-15 cm (4-6 inches) to the side of the left foot.
D) The patient ambulated 4 times with the cane in physical therapy.

Accepted Answer

The tapping sound may indicate improper use or an issue with the cane's tip, which could affect stability and safety.

Question 18

The patient is postoperative day 1 after surgery on the right knee and is to begin to walking with crutches using the three-point gait.Which action by the patient indicates the nurse needs to review the teaching?
A) Moves the right crutch first, left crutch second, and right leg last.
B) Begins in the tripod position and bears all weight on the left leg.
C) Slips three fingerbreadths between the crutch padding and the patient's axilla.
D) Flexes elbows at approximately 20 degrees while walking with crutches.

Accepted Answer

The three-point gait requires moving both crutches and the affected leg (right leg) together, not separately.

Question 19

The student nurse is reviewing Virchow's triad.What information does the student learn? (Select all that apply.)
A) Associated with arterial insufficiency.
B) Includes vessel wall abnormalities.
C) Dehydration is a cause of hypercoagulability.
D) Pregnancy can lead to venous stasis.
E) Genetically mediated risk of blood clotting.

Accepted Answer

Virchow's triad includes vessel wall abnormalities, hypercoagulability (which can be caused by dehydration), and venous stasis (which can occur during pregnancy).

Quiz 18: Exercise, Mobility, Immobilization Devices

The patient ambulates with two crutches, and the nurse notes that the patient's weight is resting on the axilla.Which intervention is best?

The health care provider prescribes partial weight bearing of the left leg for the postoperative patient.Which instruction does the nurse include in patient teaching?

A patient's pulse has gone from 78 at rest to 98 after ambulating.What nursing action is indicated at this time?

The nurse teaches the patient's caregiver how to respond if the patient begins to fall while ambulating.Which instruction does the nurse provide to minimize potential injury to the patient and the caregiver?

The nurse has assessed a patient using the Well's score and documented the score as an 8.What intervention by the nurse is most appropriate?

The patient is currently learning how to use crutches so there is minimal weight on the affected leg.Which type of crutch-walking technique will the nurse be reinforcing?

Nursing assistive personnel (NAP) are working with patients performing range-of-motion exercises.Which activity can the nurse delegate to NAP?

The nurse is planning to perform range-of-motion exercises on a patient who has had a stroke and has mobility issues.Which of the following principles does the nurse follow?

The nurse instructs the patient how to incorporate range-of-motion exercises into activities of daily living (ADLs) .With which of the patient's joints can the nurse perform the most movements for the ADLs?

The nurse is instructing a patient with a right hip replacement to descend stairs by using crutches.Which does the nurse include in patient teaching?

A patient is being moved into a dangling position before ambulating.To decrease the chance of orthostatic hypotension, what activity can the patient do?

The nurse is measuring vital signs when the patient, who is standing, reports dizziness.What is the nurse's priority intervention?

The nurse is preparing to increase the amount of ambulation that the patient is able to tolerate.Which is the best method for the nurse to assess a patient's ability to ambulate?

The nurse teaches a patient who is alert and oriented to use a cane for left leg weakness.Which does the nurse include in patient teaching?

The nurse delegates helping the older patient ambulate with a walker without wheels to nursing assistive personnel (NAP) .Which instructions does the nurse provide to the NAP?

The nurse is explaining to a nursing student the importance of making sure the patient is wearing the ordered sequential compression devices (SCDs) when in bed.Which of the following statements indicate a good understanding of the purpose of SCDs by the student? (Select all that apply.)

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 would the nurse address before the patient ambulates with the cane?

The patient is postoperative day 1 after surgery on the right knee and is to begin to walking with crutches using the three-point gait.Which action by the patient indicates the nurse needs to review the teaching?

The student nurse is reviewing Virchow's triad.What information does the student learn? (Select all that apply.)