Mobility, Positioning, And Range Of Motion - NCLEX Rn

1. When ambulating a patient with a cane, which sequence is correct for cane and weaker leg?

   Cane and weak leg advance together. Simultaneous advancement ensures stability by aligning support with the vulnerable limb during gait.

2. Which position is used for vaginal examinations and childbirth?

   Lithotomy position. Leg elevation in stirrups exposes the pelvic cavity for gynecological assessments and deliveries.

3. Which term describes ROM performed by the patient without assistance?

   Active range of motion (AROM). AROM requires patient-initiated movement to strengthen muscles and improve circulation without external aid.

4. What is the primary nursing goal of performing range-of-motion (ROM) exercises?

   Maintain joint mobility and prevent contractures. ROM exercises promote joint flexibility and muscle length to inhibit permanent shortening and deformities.

5. Which nursing action is essential before transferring a patient from bed to chair?

   Lock bed and wheelchair brakes. Securing equipment prevents unintended movement, ensuring a stable base for safe patient transfer.

6. Which joint motion is being performed when the patient moves the arm away from the body midline?

   Abduction. Lateral movement from the midline tests shoulder and hip joint integrity and muscle strength.

7. Which side should the nurse stand on when assisting a weak patient to walk with a gait belt?

   On the weaker side, slightly behind. Standing on the affected side allows optimal leverage for support and controlled assistance during mobility.

8. Which position is used to assess the back and perform many spinal procedures?

   Prone position. Face-down alignment directly exposes the dorsal surface for thorough evaluation and procedural access.

9. What is the standard nursing intervention frequency to reduce pressure injury risk in bed?

   Reposition at least every $2$ hours. Regular shifting alleviates sustained tissue compression, enhancing blood flow and reducing ischemia risk.

10. What is the correct technique if a patient reports pain during ROM of a joint?

    Stop the movement and assess; do not force ROM. Pain signals potential injury, necessitating immediate cessation and evaluation to avoid exacerbating issues like fractures.

11. Which term describes ROM performed by the patient with some assistance from the nurse?

    Active-assisted range of motion (AAROM). AAROM combines patient effort with support to gradually restore independent joint function and strength.

12. What is the recommended head-of-bed elevation to reduce aspiration risk during tube feeding?

    Elevate HOB to $30$–$45$ degrees. Semi-Fowler's position leverages gravity to minimize reflux and protect the airway during feeding.

13. Which position is commonly used for rectal exams, enemas, and some perineal procedures?

    Sims position (left lateral). Semi-prone left-sided placement provides optimal access and comfort for procedures involving the rectal or perineal area.

14. Which joint motion is being performed when the patient moves the foot upward toward the shin?

    Dorsiflexion. Ankle flexion stretches posterior leg muscles and is essential for assessing foot and lower leg mobility.

15. Which term describes ROM performed by the nurse when the patient cannot move the joint?

    Passive range of motion (PROM). PROM involves external assistance to move joints, preserving mobility when patients lack voluntary control.

16. What is the correct response if a patient begins to fall during ambulation assistance?

    Lower patient to the floor while protecting head. Guided descent minimizes impact injuries, with head safeguarding to protect against severe trauma.

17. Which position places the patient face down to improve oxygenation in selected patients?

    Prone position. Face-down positioning recruits posterior lung areas, improving ventilation-perfusion ratios in respiratory distress.

18. Which position is recommended to reduce pressure on the sacrum and coccyx?

    Side-lying (lateral) position. Lateral placement redistributes pressure from bony prominences on the back to the sides, preventing ulcers.

19. Which action best prevents shearing when repositioning a patient up in bed?

    Use a drawsheet to lift rather than drag. Lifting eliminates friction and shear forces that can damage skin layers during repositioning.

20. Which position is used to promote lung expansion and ease breathing in dyspnea?

    High Fowler position. Upright positioning at 60-90 degrees maximizes diaphragmatic movement and lung capacity for better ventilation.

21. Which gait device should be used on the stronger side when assisting a patient to ambulate?

    Cane. Placement on the unaffected side supports weight transfer and balance for the contralateral weaker limb.

22. What is the safest bed position to reduce the risk of aspiration in an unconscious patient?

    Side-lying (recovery) position. This orientation facilitates secretion drainage and maintains open airways to prevent choking in unresponsive states.

23. Which instruction is correct for using a walker during ambulation?

    Advance walker, then step with weak leg, then strong leg. This progression maintains continuous support, prioritizing the weaker limb's stability before advancing the stronger one.

24. Which joint motion is being performed when the patient turns the palm upward?

    Supination. Forearm rotation positions the palm anteriorly, evaluating pronator and supinator muscle function.

25. What is the standard nursing intervention frequency to reduce pressure injury risk in a chair?

    Reposition at least every $1$ hour. Seated positions concentrate pressure on smaller areas, requiring more frequent changes to prevent tissue damage.

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