NCLEX Style Critical Thinking Questions On Mobility

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NCLEX Style Critical Thinking Questions On Mobility

From FUNDAMENTALS SUCCESS: A Course Review Applying Critical Thinking to Test Taking by Nugent and Vitale, pages 238-251


Questions and Answers
  • 1. 
      Which nursing action is most dependent on the principle: "the wider the base of support the greater the stability"? ( p.238)
    • A. 

      Carrying a heavy object

    • B. 

      Raising the side rails on a bed

    • C. 

      Repositioning a trochanter roll

    • D. 

      Transferring a patient from a bed to a chair

  • 2. 
    What is a basic principle associated with transferring a patient from a bed to a chair using a mechanical lift? (p. 238)
    • A. 

      Hook the longer chains on the end of the sling closest to the patient's feet

    • B. 

      Ensure that there is a physician's order to use a mechanical lift

    • C. 

      Place a sheepskin inside the sling so that it is under the patient

    • D. 

      Lead with the patient's feet when existing the bed

  • 3. 
    Which position should be avoided for a patient at the greatest risk for the development of pressure ulcers?
    • A. 

      Low Fowler's

    • B. 

      Side-lying

    • C. 

      Supine

    • D. 

      Prone

  • 4. 
     Reactive hyperemia over a bony prominence occurs in response to: (p. 128)
    • A. 

      Applying a warm soak

    • B. 

      Turning a patient off an affected site

    • C. 

      Using an effleurage massage technique

    • D. 

      Pulling a patient up in bed without a pull sheet

  • 5. 
    Which motion occurs when the angle is reduced between the palm of the hand and forearm? 
    • A. 

      Hyperextension

    • B. 

      Opposition

    • C. 

      Abduction

    • D. 

      Flexion

  • 6. 
    Which is a local adaptation to immobility?
    • A. 

      Renal calculi

    • B. 

      Thrombophlebitis

    • C. 

      Muscle contractures

    • D. 

      Pathological fracture

  • 7. 
    What is the greatest potential problem associated with Low Fowler's position?
    • A. 

      Dorsiflexion contractures of the feet

    • B. 

      Pressure on the ischial tuberosities

    • C. 

      External rotation of the hips

    • D. 

      Adduction of the legs

  • 8. 
    What is the best thing a nurse can do to prevent plantar flexion when making the bed?
    • A. 

      Tuck in the top linens on just the sides of the bed

    • B. 

      Place a toe pleat in the top linens over the feet

    • C. 

      Let the top linens hang off the end of the bed

    • D. 

      Use trochanter rolls to position the feet

  • 9. 
    Which is a systemic adaptation to immobility?
    • A. 

      Plantar flexion contracture

    • B. 

      Hypostatic pneumonia

    • C. 

      Dependent edema

    • D. 

      Pressure ulcer

  • 10. 
    Which stage pressure ulcer would just have partial thickness skin loss involving epidermis and dermis?
    • A. 

      Stage I

    • B. 

      Stage II

    • C. 

      Stage III

    • D. 

      Stage IV

  • 11. 
    The most important action when assisting a patient to move from the bed to a wheelchair
    • A. 

      Applying pressure under the patient's axillae when standing up

    • B. 

      Letting the patient help as much as possible when permitted

    • C. 

      Keeping the patient's feet next to each other 1 foot apart

    • D. 

      Lowering the bed to below the height of the wheel chair

  • 12. 
    The orthopneic position is used primarily to
    • A. 

      Facilitate respirations

    • B. 

      Support hip extension

    • C. 

      Prevent pressure ulcers

    • D. 

      Promote urinary elimination

  • 13. 
    When doing ROM exercises, moving the thumb so it touches each finger is called...
    • A. 

      Flexion

    • B. 

      Inversion

    • C. 

      Abduction

    • D. 

      Opposition

  • 14. 
    An immobilized bedridden patient is placed on a 2-hour turning and positioning program primarily to:
    • A. 

      Support comfort

    • B. 

      Promote elimination

    • C. 

      Maintain skin integrity

    • D. 

      Facilitate respiratory function

  • 15. 
    Which is the most important action related to the use of antiembolism hose?
    • A. 

      Put them on after the patient's legs have been dependent for several minutes

    • B. 

      Monitor the heels for blanchable erythema every eight hours

    • C. 

      Apply body lotion before putting them on

    • D. 

      Remove and reapply them once a day

  • 16. 
    A major reason injuries occur to nurses when moving patients is because nurses:  
    • A. 

      Use the longer, rather than the shorter, muscles when moving patients

    • B. 

      Place their feet close together when transferring patients

    • C. 

      Pull rather than push when turning patients

    • D. 

      Misalign their backs when moving patients

  • 17. 
    When positioning a patient on the left side, the nurse should position the:
    • A. 

      Right leg resting on top of the left leg

    • B. 

      Knees in 90 degrees of flexion

    • C. 

      Ankles in plantar flexion

    • D. 

      Left shoulder protracted

  • 18. 
    Which motion occurs when the ankle is turned so that the sole of the foot moves medially toward the midline?
    • A. 

      Inversion

    • B. 

      Adduction

    • C. 

      Plantar Flexion

    • D. 

      Internal Rotation

  • 19. 
    What should the nurse do to quickly assess a patient's tolerance to a change in position when transferring the patient from a bed to a wheelchair? 
    • A. 

      Take the patient's blood pressure

    • B. 

      Monitor the patient for bradycardia

    • C. 

      Establish whether or not the patient feels dizzy

    • D. 

      Allow the patient time to adjust to the change in position

  • 20. 
    To best prevent pressure ulcers when a patient is on bed rest, the nurse should:
    • A. 

      Place an air mattress on the bed

    • B. 

      Massage bony prominences every shift

    • C. 

      Apply a moisture barrier to the sacral area

    • D. 

      Raise the head of the bed to the low-Fowler's position

  • 21. 
    A basic principle associated with transferring a patient using a mechanical lift
    • A. 

      Lock the base lever in open position when moving the mechanical lift

    • B. 

      Keep the wheels of the mechanical lift locked throughout the transfer

    • C. 

      Ensure that the patient's feet are protected during the transfer

    • D. 

      Raise the lift so that the patient is 6 inches off the mattress

  • 22. 
    Which complication of immobility would be of most concern? 
    • A. 

      Dehydration

    • B. 

      Incontinence

    • C. 

      Contractures

    • D. 

      Hypertension

  • 23. 
    Which stage pressure ulcer would require the nurse to measure the extent of undermining?
    • A. 

      Stage 0

    • B. 

      Stage I

    • C. 

      Stage II

    • D. 

      Stage III

  • 24. 
    Which intervention is unnecessary when assisting the patient with active range of motion exercises?
    • A. 

      Supporting above and below the joint being moved

    • B. 

      Positioning the patient in the supine position in bed

    • C. 

      Providing on-going encouragement and supervision

    • D. 

      Moving the joint through its full range at least three times

  • 25. 
    Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bedridden?
    • A. 

      Endurance

    • B. 

      Strength

    • C. 

      Support

    • D. 

      Balance

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