Mobility, Positioning, And Range Of Motion
Help Questions
NCLEX-PN › Mobility, Positioning, And Range Of Motion
A 80-year-old long-term care client with urinary incontinence is bedbound and needs repositioning. Assessment: T 98.2°F (36.8°C), HR 90, RR 18, BP 140/78, pain 4/10 when moved; skin shows nonblanchable redness on the right heel. Which positioning technique is MOST appropriate for preventing pressure ulcers?
Keep the client in a supine position to avoid friction from frequent turning
Place a donut-shaped cushion under the right heel to reduce pressure on the reddened area
Apply lotion and massage the nonblanchable heel area after each turn
Elevate the heel off the bed using a pillow under the lower leg, keeping the heel free of pressure
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is nonblanchable redness on the right heel, indicating high risk for pressure ulcer development in a bedbound client. Elevating the heel off the bed using a pillow under the lower leg is the best choice for safety and effectiveness as it completely offloads pressure from the vulnerable area. Using a donut cushion (A) can create uneven pressure; massaging the area (C) risks tissue damage; keeping supine (D) increases friction and neglects turning needs. A key decision-making principle is to prioritize pressure redistribution for high-risk areas like heels. Another principle is to avoid direct pressure on reddened skin during positioning. A transferable strategy is to incorporate heel elevation into routine turning schedules, assessing skin integrity frequently to prevent ulcer progression.
A 83-year-old long-term care client is thin, bedbound, and needs turning every 2 hours. Assessment: T 97.8°F (36.6°C), HR 82, RR 16, BP 110/66, pain 2/10; the client slides down in bed frequently. Which positioning technique is MOST appropriate for preventing pressure ulcers?
Raise the head of bed to 45 degrees for all meals and leave it elevated to prevent aspiration
Use a drawsheet to lift and reposition the client rather than dragging across the linens
Apply talcum powder to the back and buttocks after each turn to reduce friction
Place a donut cushion under the coccyx to relieve pressure while supine
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is frequent sliding down in bed, increasing shear forces and pressure ulcer risk in a thin, bedbound client. Using a drawsheet to lift and reposition the client rather than dragging is the best choice for safety and effectiveness as it minimizes friction and shear. Raising head of bed for meals (A) risks aspiration if not lowered; donut cushion (C) can cause pressure; talcum powder (D) may dry skin excessively. A key decision-making principle is to employ lift techniques to protect skin integrity. Another principle is to reposition every 2 hours to redistribute pressure. A transferable strategy is to use assistive tools like drawsheets routinely, evaluating skin after each move to prevent ulcers in immobile clients.
A 58-year-old client is 24 hours post–spinal surgery and has an order to logroll when turning. Assessment: T 98.8°F (37.1°C), HR 88, RR 18, BP 136/84, pain 6/10; the client needs repositioning in bed. Which intervention should the nurse implement FIRST for the client's mobility needs when turning the client?
Place the client in a prone position to reduce incision pressure
Request a provider order for restraints to prevent the client from moving incorrectly
Twist the client’s shoulders first, then move the hips to complete the turn
Keep the client’s shoulders, hips, and legs aligned and turn the body as a unit using a drawsheet
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is maintaining spinal alignment during turning post-spinal surgery to avoid injury. Keeping the client’s shoulders, hips, and legs aligned and turning the body as a unit using a drawsheet is the best choice for safety and effectiveness as it preserves logroll technique. Twisting shoulders first (A) risks misalignment; prone position (C) may strain incision; restraints (D) are unnecessary. A key decision-making principle is to use logrolling for spinal stability. Another principle is to involve multiple staff for safe execution. A transferable strategy is to apply alignment principles in all turns, assessing pain to ensure postoperative mobility safety.
A 73-year-old client in a long-term care facility has limited mobility and requires turning. Assessment: T 98.1°F (36.7°C), HR 86, RR 18, BP 130/72, pain 3/10; the client has fragile skin and bruises easily. Which positioning technique is MOST appropriate for preventing skin injury during repositioning?
Drag the client gently across the sheet to avoid using too much force
Keep the client in one position for 6 hours to minimize handling of the skin
Use a friction-reducing sheet or drawsheet and lift the client when moving up in bed
Massage bony prominences after repositioning to prevent bruising
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is fragile skin and easy bruising during repositioning in a limited-mobility client. Using a friction-reducing sheet or drawsheet and lifting the client when moving up in bed is the best choice for safety and effectiveness as it prevents shear and trauma. Dragging (A) causes friction; massaging prominences (C) risks bruising; prolonged positioning (D) increases ulcer risk. A key decision-making principle is to lift rather than slide for skin protection. Another principle is to use team assistance for heavy clients. A transferable strategy is to employ low-friction aids routinely, inspecting skin post-repositioning to safeguard vulnerable clients.
A 63-year-old client is 8 hours post–hernia repair and has sequential compression devices (SCDs) on both legs. Assessment: T 98.4°F (36.9°C), HR 88, RR 18, BP 124/78, pain 4/10; the client is ready to get out of bed for the first time. Which intervention should the nurse implement FIRST for the client's mobility needs related to the SCDs?
Leave the SCD sleeves on during ambulation to continue circulation support
Deflate one sleeve only so the client can pivot more easily
Turn off the SCD machine and remove the sleeves before assisting the client to stand
Ask the provider for an order to discontinue SCDs before any ambulation
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is safe removal of SCDs to prevent tripping during first post-op ambulation. Turning off the SCD machine and removing the sleeves before assisting the client to stand is the best choice for safety and effectiveness as it eliminates entanglement risks. Leaving on (B) hinders movement; discontinuing order (C) neglects DVT prevention; deflating one (D) is impractical. A key decision-making principle is to disconnect devices before mobility. Another principle is to reapply after activity for continued prophylaxis. A transferable strategy is to coordinate device use with activity plans, ensuring safety in postoperative mobility.
A 52-year-old client with a right arm cast is in a skilled nursing facility and needs range of motion to prevent stiffness. Assessment: T 98.5°F (36.9°C), HR 72, RR 16, BP 120/76, pain 3/10; fingers are warm with brisk capillary refill. What is the nurse's PRIORITY action when assisting with range of motion exercises?
Avoid any movement of the casted extremity until the cast is removed
Perform passive range of motion by bending the wrist under the cast to maintain flexibility
Remove the cast to complete full range of motion of the wrist and elbow
Perform active range of motion of the fingers and shoulder on the casted arm as tolerated
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is preventing stiffness in non-casted joints of the arm to maintain function. Performing active range of motion of the fingers and shoulder on the casted arm as tolerated is the best choice for safety and effectiveness as it promotes circulation and flexibility. Passive wrist bending under cast (B) risks injury; removing cast (C) is unauthorized; avoiding movement (D) leads to atrophy. A key decision-making principle is to exercise unrestricted joints around immobilizers. Another principle is to monitor for swelling during ROM. A transferable strategy is to encourage active participation in ROM, assessing perfusion to support recovery in casted extremities.
A 54-year-old client with a left-sided stroke 2 weeks ago is in a rehabilitation unit with right-sided weakness and requires assistance with transfers. Assessment: T 98.0°F (36.7°C), HR 78, RR 16, BP 126/74, pain 1/10; the client uses a gait belt and can bear weight on the left leg. Which intervention should the nurse implement FIRST for the client's mobility needs during a bed-to-chair transfer?
Support the weaker right arm by pulling under the axilla to guide the client to the chair
Have the client cross the legs to help pivot more quickly into the wheelchair
Ask physical therapy to perform the transfer because the client has hemiparesis
Lock the bed and wheelchair brakes and remove the wheelchair footrests before assisting the client to stand
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is safe transfer technique for a client with hemiparesis to prevent falls and injury. Locking the bed and wheelchair brakes and removing footrests before assisting the client to stand is the best choice for safety and effectiveness as it stabilizes equipment and clears obstacles. Supporting under the axilla (B) risks nerve damage and is incorrect; crossing legs (C) increases instability; delegating to physical therapy (D) neglects the nurse's role in immediate mobility needs. A key decision-making principle is to prepare the environment for transfers to minimize risks. Another principle is to use gait belts for support without compromising client dignity or safety. A transferable strategy is to assess weight-bearing ability and use step-by-step guidance, ensuring transfers promote independence while prioritizing fall prevention.
A 74-year-old client with chronic obstructive pulmonary disease is in an acute care unit and becomes short of breath when lying flat. Assessment: T 98.2°F (36.8°C), HR 90, RR 24, BP 138/80, pain 0/10; oxygen saturation is 92% on 2 L/min nasal cannula. Which positioning technique is MOST appropriate for promoting comfort and mobility in bed while reducing work of breathing?
Place the client in Trendelenburg position to improve oxygenation
Position the client prone to expand the posterior lungs
Place the client in high-Fowler position with pillows supporting the arms on an overbed table
Position the client supine with a pillow under the knees to relax the abdomen
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions. The priority concern is shortness of breath when lying flat, exacerbating work of breathing in COPD. Placing the client in high-Fowler position with pillows supporting the arms on an overbed table is the best choice for safety and effectiveness as it optimizes lung expansion and reduces dyspnea. Supine with knee pillow (B) may compress lungs; Trendelenburg (C) worsens breathing; prone (D) is uncomfortable for COPD. A key decision-making principle is to use upright positioning for respiratory relief. Another principle is to support arms to ease accessory muscle use. A transferable strategy is to monitor oxygen saturation during position changes, prioritizing comfort to enhance mobility in respiratory clients.
A 45-year-old client with multiple sclerosis is in an acute care unit for treatment of a flare and has weakness in both legs. Vital signs: T 98.5°F (36.9°C), HR 88, RR 18, BP 118/72; pain 2/10; the client requires a two-person assist for transfers from bed to chair. The nurse should QUESTION which order regarding the client's mobility care?
Encourage the client to perform active range of motion exercises to tolerance twice daily
Apply nonskid footwear before standing and keep the wheelchair locked during transfers
Use a gait belt and two-person assist for transfers from bed to chair
Transfer the client manually by having one staff member lift under the client’s arms without a gait belt
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions, specifically identifying unsafe transfer techniques. The priority concern is identifying which order poses a safety risk for both client and staff during transfers. The nurse should question transferring manually by lifting under the arms without a gait belt (Option C) because this technique risks injury to both client and staff and violates safe patient handling principles. Using a gait belt with two-person assist (Option A) is appropriate for this client's needs; active ROM exercises (Option B) promote strength and flexibility; nonskid footwear and locked wheelchairs (Option D) are essential safety measures. The decision-making principle is that all transfers should use proper equipment and body mechanics to prevent injury. A transferable strategy is to prioritize questioning any order that bypasses established safety equipment or techniques, particularly those that risk musculoskeletal injury during patient handling.
A 69-year-old client is 2 days postoperative after a left knee replacement and is on an orthopedic unit. Vital signs: T 98.8°F (37.1°C), HR 94, RR 18, BP 140/80; pain 5/10 before therapy; the client is ordered to ambulate with a walker and has an ace wrap on the operative leg. Which intervention should the nurse implement FIRST for the client's mobility needs before ambulation?
Keep the client in bed and elevate the leg for the remainder of the shift to prevent swelling
Assess pain level and administer prescribed analgesic in time for peak effect before assisting the client to stand
Have the client walk to the bathroom without the walker to increase weight bearing
Remove the ace wrap to allow full knee movement during walking
Explanation
This question tests knowledge of mobility, positioning, and range of motion interventions for postoperative knee replacement clients. The priority concern is the client's pain level (5/10) before therapy, which will impair participation in required ambulation activities. Assessing pain and administering analgesics for peak effect (Option A) is the best choice for safety and effectiveness because it ensures the client can participate comfortably in ambulation, which is crucial for recovery. Walking without the walker (Option B) eliminates needed support and violates weight-bearing precautions; removing the ace wrap (Option C) eliminates important compression for edema control; keeping the client in bed (Option D) delays necessary mobilization and increases complication risks. The decision-making principle is that adequate pain control enables participation in essential postoperative mobility activities. A transferable strategy is to prioritize timing pain medication administration to achieve peak effect during scheduled mobility sessions, maximizing client participation and progress.