Nokea
During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct Answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
You may also like to solve these questions
When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?
- A. Outer skin layer becomes less resilient.
- B. Less frequent bathing may be required.
- C. Skin becomes more subject to bruising.
- D. Sweat glands become less active.
Correct Answer: B
Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.
A healthcare professional is preparing to administer an opioid medication to a client for pain management. Which of the following actions should the healthcare professional take?
- A. Administer the medication as prescribed without any additional monitoring.
- B. Monitor the client for respiratory depression.
- C. Administer the medication only when the client requests it.
- D. Ask another healthcare professional to verify the medication before administration.
Correct Answer: B
Rationale: When administering opioid medications, it is crucial to monitor the client for respiratory depression, which is a potential side effect of opioids. Monitoring for respiratory depression is a critical safety measure to ensure the client's well-being during opioid therapy. Option A is incorrect because additional monitoring, especially for respiratory depression, is necessary when giving opioids to prevent adverse effects. Option C is incorrect as administering the medication only upon client request may compromise effective pain management and adherence to the prescribed regimen. Option D is incorrect as medication verification by another healthcare professional is essential for safety but not directly related to monitoring the client for respiratory depression after opioid administration.
An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in a Sim's position with the weight on the anterior ilium.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct Answer: C
Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.
A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?
- A. I will place the bed in the lowest position
- B. I will tighten my abdominal muscles prior to moving
- C. I will keep my legs straight to provide more power in the lift
- D. I will twist at the waist while pulling the draw sheet
Correct Answer: B
Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.
The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Avoid abbreviating medication names to prevent errors.
- C. Use generic names only for medications.
- D. Document the dosage, route of administration, and complete medication name.
Correct Answer: A
Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.