module 3 review questions with correct answers

1. A client has been on prolonged bed rest, and the nurse is observing for signs associated with
immobility. In assessment of the client, the nurse is alert to a(n):

1. Increased blood pressure

2. Decreased heart rate

3. Increased urinary output

4. Decreased peristalsis - Correct Answer Decreased peristalsis



2. A 61-year-old client recently suffered left-sided paralysis from a cerebrovascular accident (stroke). In
planning care for this client, the nurse implements which one of the following as an appropriate
intervention?

1. Encourage an even gait when walking in place.

2. Assess the extremities for unilateral swelling and muscle atrophy.

3. Encourage holding the breath frequently to hyperinflate the client's lungs.

4. Teach the use of a two-point crutch technique for ambulation. - Correct Answer Assess the
extremities for unilateral swelling and muscle atrophy.



3. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet.
Where should the nurses be standing in relation to the client's body as they prepare for the move?

1. Even with the thorax

2. Even with the shoulders

3. Even with the hips

4. Even with the knees - Correct Answer Even with the shoulders



4. A client is leaving for surgery and because of preoperative sedation needs complete assistance to
transfer from the bed to the stretcher. Which of the following should the nurse do first?

1. Elevate the head of the bed.

2. Explain the procedure to the client.

3. Place the client in the prone position.

,4. Assess the situation for any potentially unsafe complications. - Correct Answer Assess the situation
for any potentially unsafe complications.



5. A client has sequential compression stockings in place. The nurse evaluates that they are
implemented appropriately by the new staff nurse when the:

1. Initial measurement is made around the client's calves

2. Intermittent pressure is set at 40 mm Hg

3. Stockings are wrapped directly over the leg from ankle to knee

4. Stockings are removed every hour during application - Correct Answer Intermittent pressure is set at
40 mm Hg



6. The nurse assesses that the client has torticollis and that this may adversely influence the client's
mobility. This individual has a(n):

1. Exaggeration of the lumbar spine curvature

2. Increased convexity of the thoracic spine

3. Abnormal anteroposterior and lateral curvature of the spine

4. Contracture of the sternocleidomastoid muscle with a head incline - Correct Answer Contracture of
the sternocleidomastoid muscle with a head incline



7. An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon
auscultation as:

1. Harsh crackles

2. Wheezing on inspiration

3. Diminished breath sounds

4. Bronchovesicular whooshing - Correct Answer Diminished breath sounds



8. The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client
is to:

1. Measure the calf and thigh circumferences

2. Attempt to elicit Homans' sign

3. Palpate the temperature of the feet

,4. Observe for a loss of hair and skin turgor in the lower legs - Correct Answer Measure the calf and
thigh circumferences



9. A client is getting up for the first time after a period of bed rest. The nurse should first:

1. Assess respiratory function

2. Obtain a baseline blood pressure

3. Assist the client with sitting at the edge of the bed

4. Ask the client if he or she feels light-headed - Correct Answer Obtain a baseline blood pressure



10. To promote respiratory function in the immobilized client, the nurse should:

1. Change the client's position every 4 to 8 hours

2. Encourage deep breathing and coughing every hour

3. Use oxygen and nebulizer treatments regularly

4. Suction the client's secretions every hour - Correct Answer Encourage deep breathing and coughing
every hour



11. Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed rest
following surgery. The nurse explains to the client that the primary purpose for the TEDs is to:

1. Keep the skin warm and dry

2. Prevent abnormal joint flexion

3. Apply external pressure

4. Prevent bleeding - Correct Answer Apply external pressure



12. To provide for the psychosocial needs of an immobilized client, an appropriate statement by the
nurse is which of the following?

1. "The staff will limit your visitors so that you will not be bothered."

2. "A roommate can be a real bother. You'd probably rather have a private room."

3. "Let's discuss the routine to see if there are any changes we can make."

4. "I think you should have your hair done and put on some makeup." - Correct Answer "Let's discuss
the routine to see if there are any changes we can make."

, 13. To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should
implement the use of a:

1. Footboard

2. Trochanter roll

3. Trapeze bar

4. Bed board - Correct Answer Trochanter roll



14. To reduce the chance of plantar flexion (footdrop) in a client on prolonged bed rest, the nurse
should implement the use of:

1. Trapeze bars

2. High-top sneakers

3. Trochanter rolls

4. Thirty-degree lateral positioning - Correct Answer High-top sneakers



15. Which of the following is the most important to consider when assisting the client in passive range-
of-motion exercises?

1. Flex the joint to the point of discomfort.

2. Work from the proximal joints to the distal joints.

3. Quickly work through the range of motion.

4. Support the distal joints while performing range-of-motion exercises. - Correct Answer Support the
distal joints while performing range-of-motion exercises.



16. Which of the following clients is most at risk for losing his or her balance?

1. A woman who is 9 months pregnant walking down a flight of stairs

2. A 16-year-old skate boarding down a 15-degree slope

3. A 45-year-old taking hypertensive medication

4. A 4-year-old riding a tricycle - Correct Answer A woman who is 9 months pregnant walking down a
flight of stairs