Nclexrn Quiz: Mobility Positioning And Range Of Motion

20 questions · exam conditions

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Mobility Positioning And Range Of MotionQuestion 1 of 20

A 75-year-old client in a skilled nursing facility has a history of peripheral vascular disease and is mostly chair-bound. Assessment shows muscle strength 3/5 in lower extremities, limited ankle dorsiflexion, pain 2/10, and reddened areas on both ischial tuberosities after prolonged sitting. Which positioning technique should the nurse use to prevent complications?

Use a donut-shaped cushion to reduce pressure on the ischial tuberosities while sitting

Reposition the client at least every 2 hours in bed and encourage weight shifts every 15 minutes when seated, using pressure-reducing cushions

Keep the client seated upright in the chair for most of the day to promote lung expansion

Apply talcum powder to reddened areas to decrease friction and moisture

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Nclexrn Quiz: Mobility Positioning And Range Of Motion

Practice Mobility Positioning And Range Of Motion in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Mobility Positioning And Range Of Motion, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

Use a donut-shaped cushion to reduce pressure on the ischial tuberosities while sitting
Reposition the client at least every 2 hours in bed and encourage weight shifts every 15 minutes when seated, using pressure-reducing cushions (correct answer)
Keep the client seated upright in the chair for most of the day to promote lung expansion
Apply talcum powder to reddened areas to decrease friction and moisture

Explanation: This question tests clinical judgment related to mobility and positioning in a chair-bound client with peripheral vascular disease. The priority concern is preventing pressure injuries on the ischial tuberosities from prolonged sitting and limited mobility. Repositioning the client at least every 2 hours in bed and encouraging weight shifts every 15 minutes when seated, using pressure-reducing cushions, is the best choice as it distributes pressure, improves circulation, and reduces skin breakdown risk. Option A is incorrect because donut cushions can increase pressure peripherally; option C is incorrect as prolonged sitting worsens risks; option D is incorrect since talcum powder does not address pressure. The decision-making principle is to implement frequent repositioning and offloading for seated clients to mitigate vascular and immobility effects. This involves educating on self-shifts and using supportive cushions. A transferable strategy is to monitor sitting duration and skin changes, integrating pressure-relief routines into daily care for mobility-limited individuals.

Question 2

A 46-year-old client with a spinal cord injury at T6 is admitted to an inpatient rehabilitation unit. The client has paraplegia with lower extremity strength 0/5, intact upper extremity strength 5/5, no lower extremity sensation, and reports no pain. Which action should the nurse take to improve client mobility?

Perform passive range of motion of the hips, knees, and ankles daily and use footboards or splints to maintain functional alignment (correct answer)
Limit lower extremity movement to prevent spasticity and focus only on upper extremity exercises
Delegate range of motion to family members without instruction to promote independence
Position the client with pillows under the knees continuously to prevent muscle tightening

Explanation: This question tests clinical judgment related to mobility and positioning in a client with paraplegia from spinal cord injury. The priority concern is preventing contractures and maintaining lower extremity alignment in the absence of sensation and strength. Performing passive range of motion of the hips, knees, and ankles daily and using footboards or splints to maintain functional alignment is the best choice as it preserves joint mobility, prevents deformities, and supports future rehabilitation potential. Option B is incorrect because limiting movement exacerbates spasticity and contractures; option C is incorrect as delegation without instruction risks errors; option D is incorrect since pillows under knees promote flexion contractures. The decision-making principle is to employ regular range of motion and supportive devices for insensate limbs to mitigate immobility effects. This involves scheduling interventions consistently and monitoring for skin integrity. A transferable strategy is to collaborate with rehabilitation specialists to design mobility plans that include preventive positioning for long-term function.

Question 3

A 66-year-old client is post-operative day 1 after a right total knee arthroplasty. Assessment shows pain 6/10, knee flexion limited to 45 degrees, quadriceps strength 3/5, and the client is hesitant to move the operative leg. What is the nurse's PRIORITY intervention for this client's mobility needs?

Encourage early mobilization and prescribed knee range of motion exercises, coordinating analgesia timing to facilitate participation (correct answer)
Keep the operative knee immobilized in a flexed position to reduce pain and swelling
Request an order to discontinue physical therapy until pain is minimal
Assess capillary refill every hour before initiating any movement of the operative leg

Explanation: This question tests clinical judgment related to mobility and positioning in a post-operative knee arthroplasty client. The priority concern is promoting joint mobility and strength to prevent stiffness while managing pain. Encouraging early mobilization and prescribed knee range of motion exercises, coordinating analgesia timing to facilitate participation, is the best choice as it improves flexion, reduces hesitation, and enhances functional outcomes. Option B is incorrect because immobilization worsens stiffness; option C is incorrect as discontinuing therapy delays recovery; option D is lower priority since capillary refill does not preclude exercises. The decision-making principle is to synchronize pain control with mobility interventions for optimal engagement. This involves assessing readiness through strength and pain levels. A transferable strategy is to collaborate with pain management and therapy teams to time interventions, ensuring consistent progress in orthopedic rehabilitation.

Question 4

A 64-year-old client is 12 hours post-operative after a total hip arthroplasty and is ordered to ambulate with physical therapy. The client has pain 6/10 with movement, left lower extremity strength 3/5, and becomes unsteady when attempting to stand; blood pressure is stable and oxygen saturation is 97% on room air. What is the nurse's PRIORITY intervention for this client's mobility needs?

Request an order for a stronger opioid dose before attempting any mobility activity
Teach the client to avoid hip flexion greater than 90 degrees and to use an abduction pillow when in bed
Assess the surgical dressing for drainage before assisting the client out of bed
Use a gait belt and assist the client to stand and ambulate with a walker, ensuring weight-bearing status is followed (correct answer)

Explanation: This question tests clinical judgment related to mobility and positioning in a post-operative hip arthroplasty client. The priority concern is promoting safe early ambulation to prevent complications like deep vein thrombosis and deconditioning while managing pain and instability. Using a gait belt and assisting the client to stand and ambulate with a walker, ensuring weight-bearing status is followed, is the best choice as it supports safe mobility, enhances circulation, and aligns with post-hip surgery protocols for optimal recovery. Option A is lower priority because requesting stronger opioids delays mobility without addressing the immediate need; option B is incorrect as it focuses on precautions but not the priority of ambulation; option C is incorrect because dressing assessment, while important, does not directly facilitate mobility. The decision-making principle is to prioritize progressive mobility interventions that incorporate safety aids like gait belts for unstable clients. This includes monitoring vital signs and pain levels before and during activity to ensure tolerance. A transferable strategy is to collaborate with physical therapy for mobility plans and educate clients on using assistive devices to build confidence and prevent falls.

Question 5

A 68-year-old client with a new left below-the-knee amputation is in an acute rehabilitation setting. Assessment shows residual limb pain 5/10, hip strength 4/5, limited knee extension due to guarding, and the client prefers to keep a pillow under the residual limb. Which positioning technique should the nurse use to prevent complications?

Encourage the client to keep a pillow under the knee to reduce pain and prevent swelling
Position the residual limb in extension when resting (avoid pillows under the knee) and encourage prone lying as tolerated to prevent flexion contractures (correct answer)
Maintain the client in a recliner chair most of the day to increase comfort and independence
Apply a heating pad to the residual limb for 30 minutes before positioning to increase flexibility

Explanation: This question tests clinical judgment related to mobility and positioning in a client with a below-the-knee amputation. The priority concern is preventing flexion contractures in the residual limb while managing pain and promoting healing. Positioning the residual limb in extension when resting (avoid pillows under the knee) and encouraging prone lying as tolerated to prevent flexion contractures is the best choice as it maintains alignment, reduces guarding, and supports prosthetic fitting. Option A is incorrect because pillows promote contractures; option C is incorrect as prolonged reclining worsens risks; option D is incorrect since heating pads can cause burns. The decision-making principle is to promote extension positioning for amputees to preserve joint mobility. This involves educating on avoidance of flexion habits. A transferable strategy is to assess limb positioning preferences and provide alternatives like prone exercises to prevent contractures in similar cases.

Question 6

A 88-year-old long-term care resident with poor nutritional status is bedbound and incontinent. Assessment shows muscle strength 1/5, pain 2/10, and a stage 2 pressure injury on the left trochanter with partial-thickness skin loss. Which positioning technique should the nurse use to prevent complications?

Position the resident directly on the left hip to keep the wound exposed to air for faster healing
Use a 30-degree lateral position to avoid direct pressure on the trochanter and reposition on a consistent schedule (correct answer)
Place a donut cushion under the trochanter to eliminate pressure on the wound
Keep the resident in high-Fowler position to decrease pressure on the hips and improve comfort

Explanation: This question tests clinical judgment related to mobility and positioning in a bedbound resident with a trochanter pressure injury. The priority concern is offloading pressure from the wound to promote healing while addressing immobility and nutrition. Using a 30-degree lateral position to avoid direct pressure on the trochanter and reposition on a consistent schedule is the best choice as it reduces pressure, minimizes shear, and supports tissue repair. Option A is incorrect because direct pressure hinders healing; option C is incorrect as donut cushions can worsen peripheral pressure; option D is incorrect since high-Fowler increases hip pressure. The decision-making principle is to employ angled positioning to offload bony prominences in pressure injury cases. This includes scheduling turns to maintain consistency. A transferable strategy is to use wound assessment tools and integrate nutritional support with positioning plans for comprehensive prevention.

Question 7

A 62-year-old client with right-sided weakness after a stroke is in long-term care and spends most of the day in bed. Assessment shows right arm strength 1/5, right leg strength 2/5, limited shoulder external rotation, and pain 3/10 with shoulder movement. Which action should the nurse take to improve client mobility?

Support the affected arm on pillows with the shoulder in neutral alignment and perform gentle passive range of motion without pulling on the arm (correct answer)
Place the affected arm in a dependent position over the side of the bed to reduce swelling
Perform rapid, forceful range of motion to overcome stiffness and restore full mobility
Avoid any shoulder movement and focus only on hand exercises to prevent pain

Explanation: This question tests clinical judgment related to mobility and positioning in a stroke client with weakness and limited shoulder mobility. The priority concern is preventing shoulder complications like subluxation while improving range and reducing pain. Supporting the affected arm on pillows with the shoulder in neutral alignment and performing gentle passive range of motion without pulling on the arm is the best choice as it maintains positioning, enhances comfort, and preserves joint integrity. Option B is incorrect because dependent positioning worsens swelling; option C is incorrect as forceful motion causes injury; option D is incorrect since avoiding movement leads to stiffness. The decision-making principle is to use supportive elevation and gentle exercises for hemiplegic shoulders. This includes monitoring for pain to guide intensity. A transferable strategy is to integrate arm support into bedding routines and assess range regularly for progressive mobility in neurological clients.

Question 8

A 59-year-old client is 6 hours post-operative after a laparoscopic cholecystectomy. Assessment shows pain 4/10, lower extremity strength 5/5, mild nausea, and the client has not yet ambulated. Which action should the nurse take to improve client mobility?

Assist the client to sit at the edge of the bed and ambulate in the hallway with supervision as tolerated (correct answer)
Maintain bed rest until the client passes flatus to prevent dizziness and falls
Request a provider order for sequential compression device removal before ambulation
Assess the client's last bowel movement before initiating any mobility activities

Explanation: This question tests clinical judgment related to mobility and positioning in a post-operative cholecystectomy client. The priority concern is initiating early mobility to prevent complications like atelectasis and thrombosis despite mild symptoms. Assisting the client to sit at the edge of the bed and ambulate in the hallway with supervision as tolerated is the best choice as it promotes lung expansion, circulation, and recovery while ensuring safety. Option B is incorrect because bed rest until flatus delays benefits; option C is lower priority as SCD removal may not be needed; option D is incorrect since bowel movement assessment does not delay mobility. The decision-making principle is to encourage progressive ambulation early post-surgery with supervision for stability. This includes addressing nausea to facilitate participation. A transferable strategy is to use post-op protocols that include mobility milestones, assessing tolerance through symptoms for individualized progression.

Question 9

A 72-year-old long-term care resident with a history of type 2 diabetes and limited mobility after a stroke requires extensive assistance to turn in bed. Assessment shows right-sided weakness (muscle strength 2/5), cannot reposition independently, reports sacral discomfort rated 3/10, and has non-blanchable erythema over the sacrum. Which positioning technique should the nurse use to prevent complications?

Place the client supine with the head of bed at 45 degrees for comfort and keep the sacrum centered on the mattress
Reposition the client at least every 2 hours using a 30-degree lateral tilt with pillows to offload the sacrum (correct answer)
Massage the reddened sacral area for 5 minutes at each turn to improve circulation
Apply a heating pad to the sacrum for 20 minutes before turning to decrease discomfort

Explanation: This question tests clinical judgment related to mobility and positioning in a client at risk for pressure injuries. The priority concern is preventing the progression of non-blanchable sacral erythema to a pressure ulcer due to immobility and comorbidities. Repositioning the client at least every 2 hours using a 30-degree lateral tilt with pillows offloads the sacrum effectively, reducing pressure and shear forces while promoting tissue perfusion and preventing further skin breakdown. Option A is incorrect because the supine position with head elevation does not offload the sacrum; option C is incorrect as massaging reddened areas can cause tissue damage; option D is incorrect because heating pads may burn fragile skin and are not indicated for erythema. The decision-making principle is to use evidence-based repositioning techniques that minimize pressure on bony prominences in immobile clients. This involves assessing skin integrity regularly and incorporating supportive devices like pillows to maintain alignment. A transferable strategy is to perform a Braden Scale assessment to identify mobility risks and develop a tailored turning schedule that balances comfort and prevention.

Question 10

A 77-year-old long-term care resident is immobile due to advanced chronic obstructive pulmonary disease and generalized weakness. Assessment shows muscle strength 2/5, pain 3/10 in the shoulders, and developing redness on the scapulae; the resident slides down in bed frequently. Which positioning technique should the nurse use to prevent complications?

Use a drawsheet to lift and reposition the resident to reduce shear, keeping the head of bed as low as tolerated (correct answer)
Pull the resident up in bed by grasping under the axillae to correct the sliding, then support the arms with pillows to reduce shoulder discomfort.
Keep the head of the bed elevated to 90 degrees and place a pillow under the knees to prevent sliding and reduce pressure on the back.
Position the resident in a semi-prone posture on a flat bed without pillows to increase skin contact with the mattress.

Explanation: The resident is at risk for shear and pressure injury from repeated sliding, and the reddened scapulae are an early warning sign. Using a drawsheet lets staff lift and reposition the body instead of dragging skin over the sheets, so friction and shear are reduced. Keeping the head of the bed as low as tolerated lessens the downward gravitational force that causes sliding. Pulling the resident up by grasping under the axillae uses the arms and shoulders as handles; this creates shear, increases shoulder pain, and does not protect the scapulae. Keeping the head of the bed at 90 degrees makes sliding worse and increases shear and pressure; a pillow under the knees does not fix that. Positioning the resident semi-prone on a flat bed without pillows does not reduce sliding or shear, and it can leave bony areas unsupported. Therefore, the best response is the drawsheet lift repositioned technique with the lowest tolerated head-of-bed position.

Question 11

A 74-year-old client with osteoporosis is admitted after a vertebral compression fracture. The client reports back pain 8/10 with movement, lower extremity strength 5/5, and requires assistance turning in bed. Which positioning technique should the nurse use to prevent complications?

Use logrolling to turn the client while keeping the spine aligned and supporting the head, shoulders, and hips as a unit. (correct answer)
Twist the client at the waist while turning, moving the shoulders and hips separately to reduce the number of staff members needed for the turn.
Place the client in a high-Fowler position and allow sliding down in bed so gravity reduces pressure on the spine and eases the client's back pain.
Delegate turning to unlicensed assistive personnel because the client's lower-extremity strength means the client can assist with standard repositioning without special alignment.

Explanation: For a client with a vertebral compression fracture, the priority during any position change is maintaining spinal alignment. The logrolling option is correct because it keeps the head, shoulders, and hips in one straight line and avoids twist or torque on the spine. Twisting the client at the waist separates the shoulders from the hips and creates shearing force at a fracture that needs protection. High-Fowler positioning with sliding down in bed does not reduce pressure; it increases shearing and flexion along the spine and can worsen pain. Delegating to unlicensed assistive personnel is not appropriate when the client needs a specific alignment-preserving technique: strong lower extremities do not remove the need for logrolling, and the nurse must still ensure the repositioning method protects the fractured spine.

Question 12

A 65-year-old client is post-operative day 1 after a left hip fracture repair and is ordered to get out of bed with assistance. Assessment shows pain 6/10, left leg strength 3/5, orthostatic drop in blood pressure when sitting, and the client is anxious about falling. What is the nurse's PRIORITY intervention for this client's mobility needs?

Assist the client to sit and stand in stages, monitor for dizziness, use a gait belt, and ambulate with appropriate assistive device and help (correct answer)
Encourage the client to ambulate as far as possible immediately to prevent pneumonia and deep vein thrombosis, with the expectation that the client's blood pressure will normalize with activity
Obtain a provider order for continuous bed rest until orthostatic hypotension resolves, and delay ambulation until the client has stable blood pressure for 24 hours
Delegate the first ambulation to physical therapy because the client is anxious, and have physical therapy use a mechanical lift to prevent falls during the transfer

Explanation: The priority is safe, staged mobilization that addresses orthostatic hypotension, pain, weakness, and anxiety. The correct intervention gradually moves the client from sitting to standing while monitoring for dizziness, uses a gait belt, and provides appropriate assistance, directly preventing falls while promoting activity. Encouraging immediate, maximal ambulation is unsafe because it ignores orthostatic hypotension and leg weakness, raising fall risk and failing to stage activity. Obtaining a bed rest order delays needed mobility, increases risks of pneumonia and deep vein thrombosis, and contradicts the provider's order to get out of bed. Delegating the first ambulation to physical therapy because the client is anxious is inappropriate; the nurse can initiate safe mobilization and address anxiety through reassurance and staged activity. Therefore, the staged approach with safety measures is the best priority.

Question 13

A 58-year-old client with an acute ischemic stroke has left-sided hemiplegia and is on bed rest in an acute care unit. Assessment shows left arm strength 0/5, left leg strength 1/5, flaccid tone, shoulder pain 4/10 with movement, and limited passive shoulder abduction due to discomfort. Which action should the nurse take to improve client mobility?

Perform passive range of motion to the affected extremities, supporting the shoulder and moving joints slowly through the available range (correct answer)
Delegate passive range of motion to unlicensed assistive personnel because it is a basic activity of daily living, freeing the nurse for other neurologic assessments
Avoid moving the affected arm until the client regains voluntary strength, so passive movement of a flaccid joint can worsen shoulder subluxation and pain
Place a pillow directly under the axilla of the affected arm to elevate the shoulder and prevent pain during bed rest and repositioning

Explanation: Passive range of motion, supporting the shoulder and moving slowly through the available range, is correct because it maintains joint flexibility, prevents contractures, and respects the client's shoulder pain. Delegating the same activity to unlicensed assistive personnel because it is basic daily living is wrong: a flaccid hemiplegic shoulder requires the nurse's assessment of joint support and tolerance before each movement. Avoiding movement until voluntary strength returns is also wrong because immobility increases the risk of contractures and does not protect the shoulder; supported passive motion done correctly does not worsen subluxation. Placing a pillow directly under the axilla is incorrect because it positions the shoulder in an internally rotated/adducted posture, which can increase pain rather than relieve it. The priority is early, supported, pain-conscious range of motion, not avoidance, blanket delegation, or improper positioning.

Question 14

An 83-year-old client with severe osteoarthritis of both knees is admitted to a rehabilitation unit after a fall. The client reports knee pain 8/10 when the legs are fully extended, has knee flexion limited to 70 degrees bilaterally, and muscle strength 4/5 in both legs. Which positioning technique should the nurse use to prevent complications while alleviating pain?

Place pillows under the knees to maintain flexion for extended periods during the day and night, while decreasing pressure on the knee joint and relieving the client's pain.
Position the client supine with legs flat and place wedges beside the knees to limit joint movement, while keeping the hips and ankles aligned and decreasing muscle spasms.
Use a small pillow or rolled towel under the calves to float the heels and support comfort, while avoiding prolonged knee flexion. (correct answer)
Keep the client in a high-Fowler position with the knees sharply flexed to reduce joint stiffness, while elevating the legs and decreasing strain on the knee joints.

Explanation: Use the client's report: pain is 8/10 when the knees are fully extended, so a position that keeps the legs flat is unlikely to relieve pain. The safest position uses a small pillow or rolled towel under the calves because it floats the heels, keeps the knees in a neutral position, and avoids holding them in prolonged flexion. Pillows under the knees may seem soothing and can decrease joint pressure, but they leave the knees in persistent flexion, which stresses the posterior knee structures and can lead to flexion contracture. Wedges beside the knees while the legs are flat reproduce the full-extension pain the client reports, offer no heel protection, and unnecessarily limit movement. High-Fowler with the knees sharply flexed can increase pressure and stiffness in the knee joints, especially with severely limited range. The calf-supported heel-float position is the only option that balances pain relief, joint alignment, and protection from pressure injury.

Question 15

A 58-year-old client is 8 hours post-operative after abdominal surgery and has an indwelling urinary catheter and sequential compression devices. The client has incisional pain 6/10, lower-extremity muscle strength 5/5, and is reluctant to get out of bed; lung sounds are diminished at the bases. What is the nurse's PRIORITY intervention for this client's mobility needs?

Administer prescribed analgesic and then assist the client to sit, stand, and ambulate short distances as tolerated (correct answer)
Encourage the client to perform hourly deep-breathing exercises in bed and postpone getting out of bed until the next day
Obtain a provider order to discontinue the urinary catheter before the first ambulation attempt to reduce the risk of catheter dislodgement
Delegate the first ambulation to the physical therapist because the client is post-operative and requires skilled assessment during activity

Explanation: Early mobilization is the priority for this client because diminished lung sounds and reluctance to get out of bed place them at risk for atelectasis and pneumonia. The correct intervention is to give the prescribed analgesic first, then help the client sit, stand, and ambulate short distances as tolerated; treating the pain makes safe movement possible. The deep-breathing-in-bed option is incomplete: it addresses lung expansion but postpones getting out of bed until the next day, so it does not meet the client's mobility need. The option to obtain a provider order to discontinue the urinary catheter before ambulation is not required; a catheter can remain in place and be secured during ambulation, so this choice only delays care. Delegating the first ambulation to the physical therapist is also wrong because routine postoperative ambulation is a nursing intervention; waiting for physical therapy unnecessarily delays early mobility. Therefore, the only choice that directly addresses both pain and mobility is administering the analgesic and then assisting the client to sit, stand, and ambulate.

Question 16

A 45-year-old client with a C6 spinal cord injury is in an acute rehabilitation unit. The client has spasticity and limited active movement in the lower extremities (muscle strength 1/5), passive hip flexion to 80 degrees with resistance, and reports shoulder pain 3/10 from wheelchair transfers. Which action should the nurse take to improve client mobility?

Perform passive range-of-motion exercises to each lower-extremity joint slowly through the available range and stop with pain or marked resistance (correct answer)
Avoid range-of-motion exercises for the lower extremities until spasticity has completely resolved and resume after the physical therapist approves
Delegate passive range-of-motion exercises to unlicensed assistive personnel because they are routine and require a standard sequence of joint movements
Request a provider order for soft restraints to prevent contractures caused by spasticity during transfers and positioning

Explanation: The client with C6 spinal cord injury has spasticity, limited active movement, and pain from transfers; the priority is preserving joint mobility without causing harm. Performing passive range-of-motion exercises slowly through the available range and stopping with pain or marked resistance is correct because it maintains joint flexibility while respecting the limits imposed by spasticity and pain. Avoiding range-of-motion exercises until spasticity completely resolves is wrong because waiting leads to contractures and delays rehabilitation. Delegating passive range-of-motion exercises to unlicensed assistive personnel is wrong because this client's spasticity and pain require nursing assessment of resistance and discomfort; a standard sequence does not address that judgment. Requesting a provider order for soft restraints is wrong because restraints increase contracture risk and are a safety hazard, not a mobility intervention. The best action is the one that safely stretches joints and stops at the point of significant resistance, allowing the nurse to monitor the client's response.

Question 17

A 52-year-old client with multiple sclerosis is hospitalized for a urinary tract infection and has decreased mobility. The client has bilateral lower-extremity muscle strength 3/5, ankle dorsiflexion limited to 5 degrees (normal approximately 20 degrees), and reports calf tightness 4/10 during movement. Which action should the nurse take to improve client mobility?

Apply foot-drop splints and perform active-assisted range-of-motion exercises to the ankles several times daily within tolerance (correct answer)
Place pillows under the knees at rest to keep the feet relaxed and prevent the calf tightness
Assess the client's gait pattern for safety after discharge teaching is completed and before the client returns home
Delegate ankle range-of-motion exercises to the client's family members without nurse supervision to encourage independence and self-care

Explanation: The priority is preventing ankle contractures and preserving functional dorsiflexion for safe ambulation in a client at risk for foot drop. Applying foot-drop splints maintains a neutral ankle position, and active-assisted range-of-motion exercises preserve joint flexibility and muscle extensibility when performed several times daily within the client's tolerance. Placing pillows under the knees keeps the feet in a prolonged plantar-flexed position, which increases the risk of plantar flexion contracture and does not actively stretch the calf. Assessing the gait pattern for safety after discharge teaching is completed is too late — gait should be evaluated before and during teaching, and assessment alone does not improve mobility. Delegating ankle range-of-motion exercises to family members without nurse supervision is unsafe because family members lack the training to perform the exercises correctly, and unsupervised technique risks injury. The correct action is proactive: use positioning devices and active-assisted exercises immediately to prevent contractures, rather than passive comfort, delayed assessment, or unsafe delegation.

Question 18

A 71-year-old long-term care resident with chronic obstructive pulmonary disease is largely chairbound and sleeps in bed at night. The resident has thin, fragile skin, muscle strength 3/5 in the lower extremities, and reports sacral discomfort 4/10 after lying on the back; a blanchable pink area is noted on the coccyx. Which positioning technique should the nurse use to prevent complications?

Reposition the resident at least every 2 hours and use pillows or foam wedges to offload pressure from the coccyx (correct answer)
Apply talcum powder to the coccyx area after repositioning and keep the resident supine in bed to minimize movement and friction
Use a donut-shaped cushion under the coccyx to suspend the reddened area and shift pressure to the surrounding tissue while the resident is seated
Delegate skin checks of the coccyx to unlicensed assistive personnel once per shift and document the blanchable area without changing the current positioning schedule

Explanation: The safest response is the one that actually removes sustained pressure from the coccyx. Repositioning the resident at least every 2 hours and placing pillows or foam wedges under weight-bearing areas redistributes pressure and protects the blanchable area from progressing. Talcum powder with the resident kept supine is not a pressure-relief strategy; supine positioning keeps the sacrum loaded, and powder can cause moisture or irritation. A donut-shaped cushion is also contraindicated: although it appears to suspend the reddened spot, the surrounding ring compresses tissue and can impair circulation. Delegating skin checks once per shift and documenting the area without changing the positioning schedule does not address the cause, and skin observation alone cannot prevent the complication. The resident's chairbound status, fragile skin, reduced strength, and sacral discomfort all increase risk, so scheduled repositioning with pressure-relieving supports is the correct preventive technique.

Question 19

A 67-year-old client is 1 day post-operative after a total hip arthroplasty and is receiving opioid analgesics. The client reports pain 7/10 with movement, has right lower-extremity muscle strength 3/5, and becomes dizzy when sitting at the edge of the bed; blood pressure drops from 132/78 supine to 104/66 sitting. What is the nurse's PRIORITY intervention for this client's mobility needs?

Ambulate the client to the hallway with a gait belt and one-person assist to prevent venous thromboembolism
Have the client dangle at the bedside until the dizziness resolves, then stand with assistance and a walker (correct answer)
Request a provider order for a physical therapy evaluation before attempting any out-of-bed activity
Delegate initial ambulation to unlicensed assistive personnel because the client needs encouragement to move

Explanation: This question tests clinical judgment related to mobility and positioning in a post-operative client with orthostatic hypotension. The priority concern is preventing falls while promoting safe progressive mobility after hip surgery. Having the client dangle at the bedside until dizziness resolves, then stand with assistance and a walker (B) is the best choice because it addresses orthostatic hypotension through gradual position changes and ensures safety with appropriate assistive devices. Ambulating immediately to the hallway (A) is unsafe given the client's dizziness and blood pressure drop; requesting PT evaluation (C) delays necessary mobility; delegating to UAP (D) is inappropriate for an unstable client requiring nursing assessment. The decision-making principle is to progress mobility gradually while monitoring for orthostatic changes, especially in post-operative clients receiving opioids. A transferable strategy is to always assess vital signs with position changes and allow time for physiologic adaptation before advancing mobility.

Question 20

A 79-year-old long-term care resident is bedbound after a recent hip fracture and has urinary incontinence. Assessment shows muscle strength 2/5 in both legs, limited hip movement due to pain rated 5/10, and intact skin except for blanchable redness on the coccyx. Which positioning technique should the nurse use to prevent complications?

Reposition the resident every 4 hours to minimize pain from frequent movement
Keep the head of bed elevated at 60 degrees to reduce aspiration risk and prevent skin breakdown
Implement a turning schedule with at least every-2-hour repositioning and use moisture barriers while minimizing shear during turns (correct answer)
Place the resident in a prone position for 2 hours each shift to fully relieve coccyx pressure

Explanation: This question tests clinical judgment related to mobility and positioning in a bedbound resident with incontinence and hip fracture. The priority concern is preventing skin breakdown on the coccyx while managing pain and aspiration risk. Implementing a turning schedule with at least every-2-hour repositioning and using moisture barriers while minimizing shear during turns is the best choice as it reduces pressure, controls moisture, and prevents further erythema progression. Option A is incorrect because less frequent repositioning increases risk; option B is lower priority without addressing turning; option D is incorrect as prone positioning may not be tolerated and could increase discomfort. The decision-making principle is to combine frequent repositioning with skin protection strategies in incontinent, immobile clients. This includes using low-friction techniques to avoid shear injuries. A transferable strategy is to utilize risk assessment tools like the Norton Scale to guide positioning frequency and interventions for vulnerable populations.