CRITICAL CARE HESI PRACTICE QUESTIONS &
ANSWERS
(43 Q&A)
1. A nurse is assessing body alignment. What is the nurse monitoring?
The relationship of one body part to another while in different
a. positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely
ANS: A
The terms body alignment and posture are similar and refer to the positioning
of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
Body alignment means that the individual’s center of gravity is stable. Body
mechanics is a term used to describe the coordinated efforts of the
musculoskeletal and nervous systems. Friction is a force that occurs in a
direction to oppose movement. Immobility is the inability to move about freely.
2. A nurse is providing range of motion to the shoulder and must perform
external rotation. Which action will the nurse take?
a. Moves patient’s arm in a full circle
b. Moves patient’s arm cross the body as far as possible
c. Moves patient’s arm behind body, keeping elbow straight
Moves patient’s arm until thumb is upward and lateral to head with
d. elbow flexed
ANS: D
External rotation: With elbow flexed, move arm until thumb is upward and
lateral to head. Circumduction: Move arm in full circle (Circumduction is
combination of all movements of ball-and-socket joint.) Adduction: Lower 129
arm sideways and across body as far as possible. Hyperextension: Move arm
behind body, keeping elbow straight.
, 3. A nurse is providing passive range of motion (ROM) for a patient with
impaired mobility. Which technique will the nurse use for each movement?
a. Each movement is repeated 5 times by the patient.
b. Each movement is performed until the patient experiences pain.
c. Each movement is completed quickly and smoothly by the nurse.
d. Each movement is moved just to the point of resistance by the nurse.
ANS: D
Passive ROM exercises are performed by the nurse. Carry out movements
slowly and smoothly, just to the point of resistance; ROM should not cause
pain. Never force a joint beyond its capacity. Each movement needs to be
repeated 5 times during the session. The patient moves all joints through ROM
unassisted in active ROM.
4. A nurse is performing passive range of motion (ROM) and splinting on
an at-risk patient. Which finding will indicate goal achievement for the
nurse’s action?
a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures
ANS: D
Goal achievement for passive ROM is prevention of joint contractures.
Contractures develop in joints not moved periodically through their full ROM.
ROM exercises reduce the risk of contractures. Researchers noted that prompt
use of splinting with prescribed ROM exercises reduced contractures and
improved active range of joint motion in affected lower extremities. Deep
breathing and coughing and using an incentive spirometer will help prevent
atelectasis. Adequate hydration helps prevent renal calculi and urinary tract
infections.
Interventions aimed at prevention of pressure ulcers include positioning, 129
skin care, and the use of therapeutic devices to relieve pressure.
ANSWERS
(43 Q&A)
1. A nurse is assessing body alignment. What is the nurse monitoring?
The relationship of one body part to another while in different
a. positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement
d. The inability to move about freely
ANS: A
The terms body alignment and posture are similar and refer to the positioning
of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
Body alignment means that the individual’s center of gravity is stable. Body
mechanics is a term used to describe the coordinated efforts of the
musculoskeletal and nervous systems. Friction is a force that occurs in a
direction to oppose movement. Immobility is the inability to move about freely.
2. A nurse is providing range of motion to the shoulder and must perform
external rotation. Which action will the nurse take?
a. Moves patient’s arm in a full circle
b. Moves patient’s arm cross the body as far as possible
c. Moves patient’s arm behind body, keeping elbow straight
Moves patient’s arm until thumb is upward and lateral to head with
d. elbow flexed
ANS: D
External rotation: With elbow flexed, move arm until thumb is upward and
lateral to head. Circumduction: Move arm in full circle (Circumduction is
combination of all movements of ball-and-socket joint.) Adduction: Lower 129
arm sideways and across body as far as possible. Hyperextension: Move arm
behind body, keeping elbow straight.
, 3. A nurse is providing passive range of motion (ROM) for a patient with
impaired mobility. Which technique will the nurse use for each movement?
a. Each movement is repeated 5 times by the patient.
b. Each movement is performed until the patient experiences pain.
c. Each movement is completed quickly and smoothly by the nurse.
d. Each movement is moved just to the point of resistance by the nurse.
ANS: D
Passive ROM exercises are performed by the nurse. Carry out movements
slowly and smoothly, just to the point of resistance; ROM should not cause
pain. Never force a joint beyond its capacity. Each movement needs to be
repeated 5 times during the session. The patient moves all joints through ROM
unassisted in active ROM.
4. A nurse is performing passive range of motion (ROM) and splinting on
an at-risk patient. Which finding will indicate goal achievement for the
nurse’s action?
a. Prevention of atelectasis
b. Prevention of renal calculi
c. Prevention of pressure ulcers
d. Prevention of joint contractures
ANS: D
Goal achievement for passive ROM is prevention of joint contractures.
Contractures develop in joints not moved periodically through their full ROM.
ROM exercises reduce the risk of contractures. Researchers noted that prompt
use of splinting with prescribed ROM exercises reduced contractures and
improved active range of joint motion in affected lower extremities. Deep
breathing and coughing and using an incentive spirometer will help prevent
atelectasis. Adequate hydration helps prevent renal calculi and urinary tract
infections.
Interventions aimed at prevention of pressure ulcers include positioning, 129
skin care, and the use of therapeutic devices to relieve pressure.
