Question

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Lower the client to the floor.

Rationale :

🔷 Safety first: Controlled lowering prevents an uncontrolled fall, reducing impact forces to bones/soft tissue.

🔷 Wide base: Stepping into a wide base of support and sliding the client down your leg increases stability and control.

🔷 Center of gravity: Bringing the client close to your body keeps the combined center of gravity within your base for balance.

🔷 Protect the head: Guiding to the floor lets you shield the head, the most critical injury risk in falls.

🔷 Injury mitigation: This maneuver minimizes shear, twist, and sudden torque to both client and nurse.

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Answer 2

Correct Answers:

I will place a bath seat in my shower to use when I bathe."

Rationale :

🟡 High-risk area: Bathrooms are slip-prone; a bath seat lowers risk during bathing.

🟡 Energy conservation: Sitting enables rest breaks, preventing orthostatic dizziness and slips.

🟡 Transfers safer: A seat facilitates safe transfers with grab bars and reduces single-leg balance demands.

🟡 Consistent routine: Promotes habitual safety behavior, reducing variability that leads to falls.

🟡 Compatible with aids: Works well with handheld showers and nonslip mats for layered protection.

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Answer 3

Correct Answers:

Height-adjustable beds
Shower chairs
Wrist supports for computer keyboards

Rationale :

💠 Height-adjustable beds: Permit neutral spine and proper bed-to-worker height, cutting back strain.

💠 Shower chairs: Support neutral sitting and reduce sustained isometric postures in wet environments.

💠 Wrist supports: Maintain neutral wrist alignment, lowering repetitive-strain risk.

💠 Fit to task: Ergonomics means adapting equipment to the user’s body and task demands.

💠 Injury prevention: These items reduce cumulative micro-trauma, a key MSK injury driver.

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Answer 4

Correct Answers:

"Keep your back straight."

Rationale :

🔶 Neutral spine: A straight/neutral back preserves spinal curves, limiting disc and ligament stress.

🔶 Core engagement: Neutral posture encourages abdominal and gluteal co-contraction for support.

🔶 Hip/knee use: With a straight back, you naturally hinge at hips/knees, avoiding lumbar flexion.

🔶 Force transmission: Neutral alignment distributes loads efficiently through the pelvis and legs.

🔶 Injury reduction: Decreases risk of lumbar strain, herniation, and facet irritation.

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Answer 5

Correct Answers:

Reapply the bag 30 min after removing it.

Rationale :

🔵 Safe cycle: Cold is best in short applications with re-warm intervals to protect skin integrity.

🔵 Vasoconstriction window: After initial vasoconstriction/analgesia, tissues need reperfusion before re-cooling.

🔵 Injury prevention: Spacing applications reduces frostbite, nerve palsy, and pressure injury risk.

🔵 Edema control: Intermittent cold helps limit swelling while preserving capillary flow.

🔵 Protocol clarity: “Remove—wait ~30 min—reapply” is a clear, teachable routine for home use.

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Answer 6

Correct Answers:

The client's need for assistance with ADLs.
The client's ability to sit.
The condition of the client's skin.

Rationale :

🟢 Function focus: ADL assistance level reflects real-world mobility and guides equipment needs.

🟢 Sitting tolerance: Ability to sit indicates trunk control, endurance, and transfer readiness.

🟢 Skin status: Skin condition reveals pressure risk, shear exposure, and positioning needs.

🟢 Holistic mobility: These data link movement to safety, comfort, and participation in care.

🟢 Care planning: Findings drive ROM plans, turning schedules, and assistive device selection.

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Answer 7

Correct Answers:

Bend at the knees when picking up an object.

Rationale :

🟣 Legs do the work: Knee/hip flexion uses large leg muscles, sparing the lumbar spine.

🟣 Neutral core: Keeps abdominals engaged and the spine neutral during lift.

🟣 Load close: Bending properly allows holding the object close, reducing lever arm strain.

🟣 No twist: Proper setup discourages trunk twisting, a key disc injury mechanism.

🟣 Back-strain prevention: Technique lowers risk of muscle strain and facet irritation.

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Answer 8

Correct Answers:

Places mouth around mouthpiece, inhales slowly to reach the indicator, holds breath, and exhales slowly.

Rationale :

🟠 Inhale, not exhale: IS is for slow, sustained inspiration to re-expand alveoli.

🟠 Flow control: Slow inhale keeps airways open, maximizing alveolar recruitment.

🟠 End-inspiratory hold: A 2–6 s hold promotes collateral ventilation and gas exchange.

🟠 Atelectasis prevention: Regular IS reduces post-op atelectasis and pneumonia risk.

🟠 Positioning: Best done upright, with tight seal around the mouthpiece.

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Answer 9

Correct Answers:

Perform range-of-motion (ROM) exercises at least two to three times daily.
Provide an incentive spirometer and teach patient appropriate use.
Encourage the client to have a fluid intake of 2,000 mL or greater daily.
Apply antiembolic stockings to the patient's legs before getting them up in the morning.

Rationale :

🟩 Maintain joints: ROM prevents contractures, preserves joint flexibility, and improves circulation.

🟩 Pulmonary hygiene: IS use supports lung expansion, lowering atelectasis risk in immobility.

🟩 Hydration: ≥2,000 mL/day helps prevent constipation, UTIs, and thick secretions.

🟩 VTE prevention: Antiembolic stockings enhance venous return, reducing DVT risk; apply before dependent positioning.

🟩 Turn frequency: Turning should be q2h, not q4h, to protect skin and improve ventilation-perfusion.

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Answer 10

Correct Answers:

Ask the client to push her feet against the nurse's palms.

Rationale :

🔷 Direct assessment: This evaluates muscle strength in a measurable, objective way, rather than relying on subjective reports.

🔷 Lower limb focus: Pressing against resistance specifically checks leg and foot strength, which are crucial for safe ambulation.

🔷 Functional relevance: This mimics the type of effort needed when standing and walking.

🔷 Safety check: Identifies weakness that could lead to falls or imbalance during ambulation.

🔷 Clinical standard: Resistance testing is a standard nursing technique to determine readiness for mobility.

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QLexNursing

1 :
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

2 :
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

3 :
A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic?
(Select All that Apply.)

4 :
A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

6 :
A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment?
(Select All that Apply.)

7 :
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

8 :
A patient has been instructed on the use of an incentive spirometer. The nurse determines the patient understood the instructions if the patient performs which action?

9 :
A nurse on a rehabilitation unit is caring for a patient who is experiencing prolonged immobility. Which actions should the nurse plan to add to the patient's plan of care? (Select All that Apply.)

10 :
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

QLexNursing

1 : A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

2 : A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

3 : A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic?(Select All that Apply.)

4 : A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?

5 : A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

6 : A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment?(Select All that Apply.)

7 : A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

8 : A patient has been instructed on the use of an incentive spirometer. The nurse determines the patient understood the instructions if the patient performs which action?

9 : A nurse on a rehabilitation unit is caring for a patient who is experiencing prolonged immobility. Which actions should the nurse plan to add to the patient's plan of care? (Select All that Apply.)

10 : A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

1 :
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

2 :
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

3 :
A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic?
(Select All that Apply.)

4 :
A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

6 :
A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment?
(Select All that Apply.)

7 :
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

8 :
A patient has been instructed on the use of an incentive spirometer. The nurse determines the patient understood the instructions if the patient performs which action?

9 :
A nurse on a rehabilitation unit is caring for a patient who is experiencing prolonged immobility. Which actions should the nurse plan to add to the patient's plan of care? (Select All that Apply.)

10 :
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?