NCLEX MOBILITY AND IMMOBILITY PRACTICE QUESTIONS AND
ANSWERS SOLUTION
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment
you note that the patient cannot tolerate lying flat. Which of the following assessment data support a
possible pulmonary problem related to impaired mobility? (Select all that apply.)
A. B/P = 128/84
B. Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication - B. Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation
Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in
postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate
also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for
older adults because, if left untreated, further complications such as heart failure can occur.
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest
for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my
breath." Your first action is to:
A. Call the health care provider to report this change in condition.
B. Give the patient a paper bag to breathe into to decrease her anxiety.
C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
D. Explain that this is normal after such trauma and administer the ordered pain medication. - C. Assess
her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
These are signs of possible pulmonary emboli, which can be life threatening. You must assess your
patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient
to continue to monitor her status.
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the
patient that the stockings are used after a surgical procedure to:
A. Prevent varicose veins.
B. Prevent muscular atrophy.
, C. Ensure joint mobility and prevent contractures.
D. Promote venous return to the heart. - C. Ensure joint mobility and prevent contractures.
Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous
return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces
the risk for deep vein thrombosis (DVT) formation in the lower extremities.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis.
Which of the following statements made by a woman in the audience reflects a need for further
education?
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.
" - D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another
pill. "
Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet
her needs. She must know her requirement and make the decision based on that rather than on the value
for calcium on the label.
The patient at greatest risk for developing multiple adverse effects of immobility is a:
A. 1-year-old child with a hernia repair.
B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
C. 51-year-old woman following a thyroidectomy.
D. 38-year-old woman undergoing a hysterectomy. - B. 80-year-old woman who has suffered a
hemorrhagic cerebrovascular accident (CVA).
The older the patient and the greater the period of immobility, which can be significant following a
hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days.
Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the
first time?
A. Chronic pain
ANSWERS SOLUTION
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment
you note that the patient cannot tolerate lying flat. Which of the following assessment data support a
possible pulmonary problem related to impaired mobility? (Select all that apply.)
A. B/P = 128/84
B. Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication - B. Respirations 26 per minute on room air
C. HR 114
D. Crackles heard on auscultation
Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in
postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate
also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for
older adults because, if left untreated, further complications such as heart failure can occur.
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest
for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my
breath." Your first action is to:
A. Call the health care provider to report this change in condition.
B. Give the patient a paper bag to breathe into to decrease her anxiety.
C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
D. Explain that this is normal after such trauma and administer the ordered pain medication. - C. Assess
her vital signs, perform a respiratory assessment, and be prepared to start oxygen.
These are signs of possible pulmonary emboli, which can be life threatening. You must assess your
patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient
to continue to monitor her status.
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the
patient that the stockings are used after a surgical procedure to:
A. Prevent varicose veins.
B. Prevent muscular atrophy.
, C. Ensure joint mobility and prevent contractures.
D. Promote venous return to the heart. - C. Ensure joint mobility and prevent contractures.
Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous
return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces
the risk for deep vein thrombosis (DVT) formation in the lower extremities.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis.
Which of the following statements made by a woman in the audience reflects a need for further
education?
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill.
" - D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another
pill. "
Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet
her needs. She must know her requirement and make the decision based on that rather than on the value
for calcium on the label.
The patient at greatest risk for developing multiple adverse effects of immobility is a:
A. 1-year-old child with a hernia repair.
B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA).
C. 51-year-old woman following a thyroidectomy.
D. 38-year-old woman undergoing a hysterectomy. - B. 80-year-old woman who has suffered a
hemorrhagic cerebrovascular accident (CVA).
The older the patient and the greater the period of immobility, which can be significant following a
hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days.
Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the
first time?
A. Chronic pain
