NCLEX Mobility and Immobility Practice Exam
A nurse is caring for a patient who is at risk for immobility. Which of the following interventions should the nurse prioritize?
A) Encourage bed rest
B) Assist with passive range of motion exercises
C) Restrict oral intake
D) Monitor vital signs every 8 hours
A nurse is providing care for a patient with a lower leg fracture. Which of the following complications is the patient at greatest risk for due to immobility?
A) Pressure ulcers
B) Deep vein thrombosis (DVT)
C) Hyperglycemia
D) Renal failure
Which of the following is a priority assessment for a patient on prolonged bed rest?
A) Skin integrity
B) Respiratory rate
C) Muscle strength
D) Urinary output
A nurse is teaching a patient with a hip replacement how to reduce the risk of dislocation. Which of the following instructions should the nurse include?
A) Cross your legs at the ankles
B) Keep your hip in a neutral position
C) Sit in a low chair
D) Bend your hip past 90 degrees when sitting
A nurse is caring for a patient with a spinal cord injury at the T6 level. The nurse should monitor the patient for which of the following complications related to immobility?
A) Hypotension
B) Hyperkalemia
C) Deep vein thrombosis (DVT)
D) Increased appetite
A patient is admitted with severe muscle weakness and immobility. Which of the following nursing diagnoses is a priority?
A) Impaired physical mobility
B) Risk for injury
C) Acute pain
D) Ineffective breathing pattern
Which of the following is an effective intervention for preventing immobility complications in a postoperative patient?
A) Encourage the patient to remain in bed for the first 72 hours
B) Provide frequent, small meals to maintain energy
C) Encourage early ambulation and deep breathing exercises
D) Place the patient in a prone position to avoid pressure ulcers
A nurse is caring for a patient with a fractured femur. Which of the following interventions is most appropriate for preventing venous thromboembolism (VTE)?
A) Apply anti-embolism stockings
B) Increase the patient’s oral fluid intake
C) Encourage leg exercises every 2 hours
D) Administer anticoagulants as prescribed
A nurse is educating a patient about the importance of early ambulation after surgery. Which of the following is the most important benefit of early ambulation for this patient?
A) Reduces the risk of pneumonia
B) Prevents constipation
C) Improves sleep patterns
D) Helps with wound healing
Which of the following is a common consequence of prolonged immobility?
A) Increased muscle mass
B) Increased bone density
C) Decreased lung expansion
D) Increased circulation
A nurse is planning care for a patient with a spinal cord injury. Which of the following interventions is essential for preventing complications related to immobility?
A) Provide a high-protein diet
B) Assist with weight-bearing exercises
C) Perform passive range-of-motion exercises
D) Encourage fluids to prevent dehydration
Which of the following is the best nursing action to prevent pressure ulcers in an immobile patient?
A) Turn the patient every 4 hours
B) Maintain the patient’s head of the bed elevated at 30 degrees
C) Apply moisture barriers to the skin
D) Ensure the patient has adequate nutritional intake
A patient is receiving a hip replacement surgery. Which of the following positions is recommended to prevent dislocation postoperatively?
A) Supine with the affected leg in a neutral position
B) Side-lying with the hip flexed at 90 degrees
C) Supine with the knee extended
D) Prone with the affected leg raised
A nurse is caring for a patient on bed rest. Which of the following is the most important nursing intervention to prevent complications from immobility?
A) Encourage fluid intake to prevent dehydration
B) Provide passive range of motion exercises
C) Increase dietary protein for wound healing
D) Keep the head of the bed elevated to prevent aspiration
A nurse is assessing a patient with limited mobility. The nurse notes that the patient has contractures in both lower limbs. What is the best intervention for this patient?
A) Massage the limbs to relieve tension
B) Apply warm compresses to the limbs
C) Perform daily passive range of motion exercises
D) Encourage active exercises in the upper limbs
A nurse is caring for a patient recovering from knee surgery. Which of the following interventions should be implemented to improve the patient’s mobility?
A) Encourage frequent periods of complete bed rest
B) Gradually increase the patient’s weight-bearing activity as tolerated
C) Avoid using assistive devices like crutches
D) Limit range-of-motion exercises to avoid pain
Which of the following interventions is appropriate for a patient with a hip replacement to prevent post-operative complications?
A) Limit fluid intake to prevent edema
B) Maintain a neutral position of the hip to prevent dislocation
C) Keep the patient in bed for extended periods to promote rest
D) Perform active range of motion exercises immediately after surgery
A nurse is caring for a patient with decreased mobility due to a stroke. Which of the following should the nurse prioritize in the care plan?
A) Promote independence in all activities of daily living
B) Encourage passive range of motion exercises to prevent contractures
C) Ensure the patient is positioned supine at all times
D) Administer pain medications regularly to ensure comfort
A nurse is caring for a patient who has been on bed rest for 3 days. Which of the following complications is the patient most at risk for?
A) Hyperglycemia
B) Hypertension
C) Deep vein thrombosis
D) Hypokalemia
A nurse is educating a patient about using crutches after leg surgery. Which of the following is an appropriate instruction?
A) Use the crutches to support weight on the injured leg
B) Keep the crutches 12 inches in front of you when walking
C) Place the crutches under the armpits for support
D) Bend the elbows to a 90-degree angle when using crutches
Which of the following should be included in a plan of care for a patient at risk for pressure ulcers?
A) Encourage frequent repositioning every 2 hours
B) Limit the patient’s fluid intake to prevent incontinence
C) Keep the patient in a supine position to promote circulation
D) Avoid using pillows for positioning to reduce pressure
Which of the following is a common effect of immobility on the respiratory system?
A) Increased lung expansion
B) Increased oxygenation
C) Decreased lung expansion
D) Decreased respiratory rate
A nurse is planning care for a patient who is immobile. Which of the following is an appropriate intervention to prevent urinary complications?
A) Encourage increased fluid intake
B) Limit fluid intake to prevent edema
C) Position the patient in a prone position
D) Restrict ambulation to avoid falls
A patient with severe immobility has developed pressure ulcers. Which of the following should be a priority in the care plan?
A) Monitor vital signs closely
B) Provide high-protein supplements to promote healing
C) Maintain strict bed rest to prevent further injury
D) Administer analgesics for pain management
A nurse is assessing a patient with a hip fracture. Which of the following interventions is essential for reducing the risk of complications related to immobility?
A) Frequent repositioning every 2 hours
B) Ensure the patient has an adequate diet for healing
C) Keep the patient’s leg elevated above the heart
D) Avoid any weight-bearing activity until cleared by the physician
A patient recovering from spinal surgery is at risk for complications related to immobility. Which of the following should be included in the care plan?
A) Strict bed rest without any movement
B) Regular assessment of skin integrity
C) Encourage the patient to remain in a supine position
D) Administer pain medications only when requested
A patient on prolonged bed rest is at risk for constipation. Which of the following interventions should the nurse prioritize?
A) Increase fluid intake
B) Provide a high-protein diet
C) Restrict dietary fiber
D) Administer laxatives regularly
Which of the following is a key goal when caring for an immobile patient?
A) Maintaining muscle tone and strength
B) Preventing immobility-related complications
C) Limiting the range of motion exercises
D) Ensuring the patient remains supine at all times
A nurse is caring for a patient with a lower extremity amputation. What is an appropriate intervention for this patient to promote mobility?
A) Encourage the use of a walker as soon as possible
B) Apply a prosthesis immediately after surgery
C) Initiate passive range-of-motion exercises
D) Keep the leg elevated to prevent swelling
A nurse is teaching a patient about proper posture to prevent musculoskeletal complications. Which of the following statements should the nurse include?
A) Always sit with your knees higher than your hips
B) Bend forward at the waist when lifting objects
C) Avoid long periods of sitting or standing in one position
D) Cross your legs when sitting for long periods of time
A nurse is caring for a patient who has been on strict bed rest for 5 days. Which of the following is the greatest risk to this patient’s health?
A) Hypovolemia
B) Decreased appetite
C) Pulmonary embolism
D) Muscle hypertrophy
A patient with limited mobility is at risk for developing urinary retention. Which of the following interventions is most appropriate?
A) Encourage frequent fluid intake
B) Encourage the patient to perform pelvic floor exercises
C) Position the patient upright during voiding
D) Restrict fluid intake to prevent overhydration
A nurse is caring for a patient who has had a stroke and is experiencing impaired mobility. Which of the following interventions will help prevent the development of contractures?
A) Encourage the patient to perform isometric exercises
B) Perform passive range-of-motion exercises daily
C) Apply warm compresses to affected limbs
D) Limit movement of the affected extremity to prevent pain
A nurse is caring for a patient post-hip replacement surgery. Which of the following is the most important action to prevent complications?
A) Keep the affected leg in a neutral position
B) Perform weight-bearing exercises immediately
C) Ensure the patient remains in a prone position
D) Allow the patient to cross legs for comfort
A nurse is teaching a patient about the prevention of deep vein thrombosis (DVT) during a long hospital stay. Which of the following statements by the patient indicates understanding?
A) “I will try to remain in bed as much as possible.”
B) “I will perform leg exercises every hour.”
C) “I will increase my fluid intake but avoid movement.”
D) “I will stay in one position for long periods of time.”
A nurse is caring for a patient with a spinal cord injury. Which of the following should the nurse include in the plan of care to prevent complications of immobility?
A) Keep the patient in a low Fowler’s position at all times
B) Encourage the patient to sit up in a chair for several hours each day
C) Administer stool softeners to prevent constipation
D) Apply warm compresses to the legs to reduce muscle spasms
A nurse is assessing a patient who has been immobile for several weeks. Which of the following signs suggests the development of a pressure ulcer?
A) Redness that does not blanch
B) Increased skin temperature
C) Increased swelling
D) Pain and discomfort in the affected area
A patient recovering from knee surgery is prescribed physical therapy to improve mobility. Which of the following interventions should the nurse recommend to promote mobility?
A) Apply ice packs to the knee for 20 minutes before exercising
B) Perform active range-of-motion exercises daily
C) Perform exercises that increase the weight load on the knee
D) Limit movement of the knee to prevent pain
A nurse is caring for a patient with chronic immobility. Which of the following should be a priority in the care plan?
A) Encourage fluid intake to prevent dehydration
B) Provide pressure relief surfaces to reduce the risk of pressure ulcers
C) Restrict sodium intake to prevent fluid retention
D) Promote long periods of bed rest to reduce fatigue
Which of the following interventions is the most appropriate to help prevent immobility complications in a postoperative patient?
A) Administer pain medication to keep the patient sedated
B) Encourage the patient to turn, cough, and deep breathe every hour
C) Keep the patient in bed with minimal movement for 24 hours
D) Limit fluid intake to prevent discomfort
A nurse is assessing a patient with limited mobility. Which of the following findings should the nurse report immediately to the healthcare provider?
A) Increased urinary output
B) Complaints of calf pain and swelling
C) Mild redness of the skin
D) Decreased appetite
A nurse is teaching a patient with mobility issues how to prevent joint contractures. Which of the following should the nurse include in the teaching plan?
A) Maintain joints in a flexed position as much as possible
B) Perform range-of-motion exercises at least twice a day
C) Immobilize the affected joints with braces or splints
D) Encourage weight-bearing exercises to strengthen muscles
A nurse is caring for a patient with paraplegia. Which of the following should the nurse monitor closely to detect complications related to immobility?
A) Bowel sounds
B) Respiratory rate
C) Skin integrity
D) Electrolyte levels
Which of the following nursing interventions is most effective for preventing the complications of immobility in a postoperative patient?
A) Keep the patient on bed rest for as long as possible
B) Encourage frequent position changes and early ambulation
C) Restrict fluids to prevent edema and swelling
D) Provide a high-fat, low-carbohydrate diet
A nurse is caring for a patient who is unable to bear weight on his legs due to a knee injury. Which of the following devices will best promote mobility for this patient?
A) Cane
B) Walker
C) Crutches
D) Wheelchair
A patient is experiencing difficulty with mobility after surgery. Which of the following should the nurse recommend to improve the patient’s muscle strength and function?
A) Encourage the patient to stay in bed and rest
B) Start a rehabilitation program to strengthen the muscles
C) Avoid using assistive devices to promote independence
D) Keep the affected limb elevated and immobile
A nurse is caring for a patient with limited mobility. Which of the following interventions would help prevent pressure ulcers?
A) Apply powder to the patient’s skin to reduce friction
B) Reposition the patient at least every 2 hours
C) Keep the patient in a supine position only
D) Use elastic stockings to promote circulation
A patient is recovering from a stroke and is unable to move the right side of the body. Which of the following interventions should the nurse prioritize?
A) Teach the patient to rely on the left side for all activities
B) Assist with passive range-of-motion exercises for the affected side
C) Encourage the patient to stay in bed to conserve energy
D) Immobilize the affected limbs to reduce pain
Which of the following is an important intervention to prevent pulmonary complications in a patient with limited mobility?
A) Perform deep breathing and coughing exercises regularly
B) Provide oxygen therapy at all times
C) Position the patient in a supine position with the head of the bed flat
D) Encourage the patient to avoid speaking to conserve energy
A patient with a history of immobility is being discharged home. Which of the following interventions should the nurse include in the discharge teaching plan?
A) Limit daily physical activity to prevent fatigue
B) Avoid using assistive devices to promote independence
C) Increase fluid intake and incorporate ambulation into daily routine
D) Rest and avoid all physical activity for the first week after discharge
A nurse is caring for a patient who is on prolonged bed rest. Which of the following interventions is most important to prevent deep vein thrombosis (DVT)?
A) Elevate the legs above the heart level
B) Encourage the patient to drink fluids frequently
C) Apply compression stockings as ordered
D) Keep the patient in a lateral position at all times
A nurse is teaching a patient who is recovering from knee surgery how to use a walker. Which of the following is the correct way to use the walker?
A) The patient should keep the walker in front of them and move both legs forward at the same time.
B) The patient should move the walker forward and then step into the walker with one leg at a time.
C) The patient should bend at the waist while using the walker for support.
D) The patient should lean on the walker for full weight-bearing support.
A nurse is caring for a patient who has been immobile for an extended period. Which of the following is the most common complication associated with immobility?
A) Hyperthermia
B) Constipation
C) Hypertension
D) Hypoglycemia
A nurse is assisting a patient who has difficulty ambulating. Which of the following assistive devices is most appropriate for a patient with severe leg weakness but good balance?
A) Walker
B) Cane
C) Crutches
D) Wheelchair
A nurse is caring for a patient with chronic immobility due to a spinal cord injury. Which of the following interventions is essential to prevent skin breakdown?
A) Perform passive range-of-motion exercises twice a day
B) Reposition the patient at least every 2 hours
C) Apply lotion to the skin to reduce friction
D) Keep the patient in one position for long periods to prevent pain
A nurse is assessing a patient for signs of joint contractures. Which of the following would indicate the presence of a contracture?
A) Increased muscle tone
B) Joint stiffness and inability to fully extend
C) Decreased muscle strength
D) Increased range of motion
A nurse is caring for a patient with limited mobility due to a stroke. Which of the following interventions should the nurse implement to prevent complications of immobility?
A) Encourage the patient to remain in bed for as long as possible
B) Encourage the patient to perform active range-of-motion exercises daily
C) Keep the affected limbs immobile to prevent pain
D) Keep the patient in one position to avoid excessive movement
A patient recovering from surgery is instructed to ambulate several times a day. Which of the following is the most important safety consideration?
A) Ensure the patient has a stable, well-supported surface to ambulate
B) Ensure the patient performs deep breathing exercises before ambulation
C) Encourage the patient to ambulate as quickly as possible to improve circulation
D) Ensure the patient is wearing non-slip footwear before walking
A nurse is teaching a patient about the prevention of osteoporosis related to immobility. Which of the following should the nurse include in the teaching?
A) Increase calcium and vitamin D intake
B) Limit physical activity to avoid stress on the bones
C) Avoid weight-bearing exercises to prevent fractures
D) Increase the intake of high-protein foods
A nurse is assessing a patient post-hip replacement. Which of the following interventions should the nurse include in the care plan to prevent hip dislocation?
A) Keep the hip in an abducted position with a pillow between the legs
B) Allow the patient to cross their legs at the knee
C) Encourage the patient to bend their hip when sitting
D) Perform range-of-motion exercises for the affected leg
A nurse is teaching a patient with limited mobility about the importance of adequate nutrition. Which of the following should the nurse emphasize?
A) A low-protein, high-carbohydrate diet
B) A high-fiber diet to prevent constipation
C) A high-fat diet to increase energy intake
D) A low-sodium diet to reduce swelling
A nurse is caring for a patient who is at risk for developing a pressure ulcer. Which of the following interventions is most effective in preventing pressure ulcers in a bedridden patient?
A) Reposition the patient every 2 hours
B) Apply a pressure-relieving mattress and pillows
C) Restrict fluid intake to decrease pressure
D) Massage the patient’s skin to improve circulation
A nurse is teaching a patient with limited mobility about the prevention of venous thromboembolism (VTE). Which of the following should the nurse include in the teaching plan?
A) Perform leg exercises every 2 hours
B) Stay in a supine position for long periods
C) Apply heat to the legs to improve circulation
D) Avoid fluid intake to reduce swelling
A nurse is caring for a patient post-stroke who has hemiplegia. Which of the following interventions should be included in the care plan to prevent shoulder subluxation?
A) Keep the arm in a position of elevation at all times
B) Avoid supporting the arm in an adducted position
C) Immobilize the arm in a sling during the day
D) Limit range-of-motion exercises for the shoulder
A nurse is assisting a patient with limited mobility to perform range-of-motion exercises. Which of the following is the correct approach to passive range-of-motion exercises?
A) The nurse should move the joint to the point of resistance and stop
B) The nurse should encourage the patient to do the exercises independently
C) The nurse should allow the patient to move the joint with minimal assistance
D) The nurse should use forceful movements to increase joint flexibility
A nurse is caring for a patient who is bedridden and at risk for urinary retention. Which of the following interventions should the nurse implement?
A) Encourage the patient to limit fluid intake to reduce the need to void
B) Assist the patient to a seated position or use a bedpan for urination
C) Perform intermittent catheterization every 2 hours
D) Keep the patient in a supine position to prevent bladder discomfort
A nurse is caring for a patient with limited mobility due to arthritis. Which of the following interventions will help improve joint mobility?
A) Apply hot packs to the joints before exercising
B) Limit the range of motion exercises to avoid stress on the joints
C) Perform joint immobilization for long periods to reduce pain
D) Encourage weight-bearing activities to increase muscle strength
A nurse is assessing a patient for signs of dehydration due to immobility. Which of the following findings should the nurse report to the healthcare provider?
A) Increased urine output
B) Decreased skin turgor
C) Moist mucous membranes
D) Regular bowel movements
A nurse is planning care for a patient who is at risk for muscle atrophy due to immobility. Which of the following is the best intervention to prevent muscle atrophy?
A) Encourage the patient to perform deep breathing exercises
B) Provide passive range-of-motion exercises
C) Encourage frequent repositioning
D) Administer medications to improve muscle strength
A nurse is caring for a patient with spinal cord injury. Which of the following should the nurse include in the care plan to prevent autonomic dysreflexia?
A) Maintain a neutral position with head slightly elevated
B) Monitor for signs of excessive perspiration and chills
C) Perform passive range-of-motion exercises every hour
D) Ensure the bladder is emptied regularly to prevent urinary retention
A nurse is teaching a patient about the importance of maintaining mobility during recovery from surgery. Which of the following is the most important benefit of mobility?
A) Improved muscle strength
B) Decreased circulation
C) Increased risk of blood clots
D) Reduced joint flexibility
A nurse is caring for a patient who has limited mobility due to a fractured femur. Which of the following interventions should the nurse implement to prevent complications related to immobility?
A) Provide passive range-of-motion exercises twice daily
B) Encourage fluid intake to prevent dehydration
C) Keep the patient in bed for as long as possible to rest
D) Apply compression stockings to prevent DVT
A nurse is caring for a patient with limited mobility due to a recent stroke. Which of the following interventions should the nurse prioritize to prevent contractures?
A) Encourage the patient to perform active range-of-motion exercises
B) Immobilize the affected limb to prevent movement
C) Reposition the patient every 4 hours
D) Apply a compression bandage to the affected limb
A nurse is teaching a patient with a hip replacement how to prevent complications. Which of the following should the nurse include in the teaching?
A) Cross the legs when sitting to improve circulation
B) Avoid bending the hip beyond a 90-degree angle
C) Keep the surgical leg in an adducted position
D) Use a walker only when feeling unstable
A nurse is caring for a patient with a history of deep vein thrombosis (DVT). Which of the following interventions is most appropriate for preventing future DVTs in an immobile patient?
A) Encourage the patient to maintain a flat position in bed
B) Administer anticoagulant medications as prescribed
C) Apply a heating pad to the affected area
D) Restrict fluid intake to prevent swelling
A nurse is assisting a patient with transferring from the bed to a chair. Which of the following is the most important safety precaution?
A) Ask the patient to lift themselves using the arms
B) Make sure the patient wears non-slip footwear
C) Allow the patient to transfer independently
D) Keep the patient’s bed in a flat position
A nurse is caring for a patient who is immobile and at risk for pressure ulcers. Which of the following is the best intervention to prevent skin breakdown?
A) Use a foam mattress overlay
B) Massage the patient’s skin every 4 hours
C) Apply lotion to dry skin to increase elasticity
D) Keep the patient in a supine position for long periods
A nurse is caring for a patient recovering from a lower extremity amputation. Which of the following interventions should the nurse implement to promote mobility?
A) Encourage the patient to remain in bed for the first 24 hours
B) Teach the patient to use a prosthesis as soon as possible
C) Limit range-of-motion exercises to prevent pain
D) Reposition the patient every 6 hours
A nurse is caring for a patient who has been immobile for an extended period. Which of the following is an early sign of deep vein thrombosis (DVT)?
A) Pallor of the affected limb
B) Increased peripheral pulses
C) Swelling and warmth of the affected limb
D) Cyanosis of the toes
A nurse is teaching a patient with limited mobility about the importance of increasing fiber in the diet. Which of the following is the most important benefit of dietary fiber for an immobile patient?
A) Increases energy levels
B) Prevents constipation
C) Enhances muscle strength
D) Reduces urinary incontinence
A nurse is assessing a patient for signs of immobility-related complications. Which of the following is the most common complication of immobility in the elderly?
A) Increased mobility
B) Pneumonia
C) Urinary tract infections
D) Pressure ulcers
A nurse is caring for a patient recovering from knee surgery. Which of the following interventions should the nurse include in the plan of care to promote mobility?
A) Encourage the patient to remain in bed for 48 hours
B) Assist the patient with gradual range-of-motion exercises
C) Restrict ambulation to the bathroom only
D) Apply ice to the knee for 48 hours to limit movement
A nurse is teaching a patient with a spinal cord injury how to prevent autonomic dysreflexia. Which of the following should the nurse include in the teaching?
A) Increase fluid intake to prevent dehydration
B) Monitor blood pressure regularly
C) Avoid using a catheter to manage urinary incontinence
D) Wear tight-fitting clothing to prevent pressure sores
A nurse is caring for a patient on prolonged bed rest. Which of the following should the nurse include in the care plan to reduce the risk of muscle atrophy?
A) Encourage the patient to remain in a supine position
B) Provide range-of-motion exercises for the affected limbs
C) Increase the patient’s calorie intake to promote weight gain
D) Apply a heating pad to the affected muscles
A nurse is teaching a patient with arthritis about joint protection. Which of the following should the nurse emphasize?
A) Perform high-impact exercises to strengthen joints
B) Use assistive devices for tasks that require lifting
C) Avoid joint rest to increase flexibility
D) Always wear tight-fitting shoes to support the joints
A nurse is caring for a patient with a history of strokes and limited mobility. Which of the following interventions is most important to prevent falls?
A) Keep the bed in the high position to prevent aspiration
B) Keep the patient’s room dimly lit to promote sleep
C) Ensure the patient’s call light is within reach
D) Restrict the patient’s fluid intake to reduce bathroom trips
A nurse is caring for a patient on strict bed rest. Which of the following is the most important intervention to prevent respiratory complications?
A) Encourage coughing and deep breathing exercises
B) Administer sedatives to help the patient relax
C) Keep the head of the bed elevated at all times
D) Apply oxygen therapy to increase oxygen saturation
A nurse is teaching a patient about the prevention of urinary retention while on bed rest. Which of the following should the nurse include in the teaching?
A) Drink a large amount of fluid before bedtime
B) Limit fluid intake to prevent bladder distension
C) Encourage the patient to void at regular intervals
D) Keep the patient in a supine position for comfort
A nurse is caring for a patient who is recovering from a hip replacement surgery. Which of the following is the most appropriate position for the patient to prevent dislocation?
A) Keep the affected hip in an adducted position
B) Use pillows to maintain an abducted position of the leg
C) Allow the patient to sit cross-legged after 24 hours
D) Keep the patient’s hip in a neutral position at all times
A nurse is assisting a patient with limited mobility to transfer from the bed to a chair. Which of the following should the nurse do to reduce the risk of injury?
A) Encourage the patient to use a pivot technique
B) Allow the patient to perform the transfer independently
C) Use a lifting device to assist the transfer
D) Provide a step stool to elevate the patient’s legs
A nurse is caring for a patient with a history of osteoporosis. Which of the following interventions should be implemented to improve mobility and prevent fractures?
A) Limit weight-bearing exercises to avoid fractures
B) Provide a high-protein diet to increase bone strength
C) Encourage weight-bearing activities like walking
D) Ensure the patient is sedentary to prevent stress on the bones
A nurse is caring for a patient who has been immobile for several days. The nurse is concerned about the risk of a pulmonary embolism. Which of the following is a priority intervention?
A) Elevate the patient’s legs above heart level
B) Encourage the patient to cough and deep breathe
C) Keep the patient in a supine position to minimize exertion
D) Apply compression stockings to the lower extremities
A nurse is caring for a patient with a cast on the left leg. Which of the following is the most important intervention to prevent complications related to immobility?
A) Elevate the left leg to reduce swelling
B) Apply heat to the cast to alleviate pain
C) Restrict the patient’s movement to prevent further injury
D) Use a heating pad to reduce muscle spasms
A nurse is caring for a patient with limited mobility due to an orthopedic injury. Which of the following is the best intervention to prevent muscle atrophy?
A) Encourage the patient to perform passive range-of-motion exercises
B) Immobilize the affected limbs for as long as possible
C) Avoid any form of movement to reduce pain
D) Administer muscle relaxants to prevent spasms
A nurse is assisting a patient with the use of a wheelchair. Which of the following is the most important safety precaution?
A) Lock the wheelchair brakes before transferring the patient
B) Allow the patient to self-propel without supervision
C) Keep the footrests in a raised position at all times
D) Ensure the patient is seated in a fully reclined position
A nurse is caring for a patient with a lower limb fracture. Which of the following interventions is most important to prevent complications from immobility?
A) Encourage the patient to rest and limit movement of the limb
B) Administer pain medications every 4 hours as prescribed
C) Perform passive range-of-motion exercises on the unaffected joints
D) Apply ice to the fracture site every 6 hours
A nurse is teaching a patient recovering from knee surgery about preventing deep vein thrombosis (DVT). Which of the following interventions should the nurse emphasize?
A) Avoid ambulation until the leg is fully healed
B) Wear compression stockings as prescribed
C) Take a hot bath daily to improve circulation
D) Limit fluid intake to prevent swelling
A nurse is caring for a patient who is at risk for pressure ulcers. Which of the following is the best intervention to prevent pressure ulcers in an immobile patient?
A) Reposition the patient every 2 hours
B) Massage the patient’s skin regularly
C) Provide frequent baths to prevent skin infections
D) Apply a thick layer of lotion to the skin
A nurse is caring for a patient who is bedridden. Which of the following interventions should the nurse implement to prevent urinary retention?
A) Encourage the patient to drink plenty of fluids
B) Restrict fluid intake to reduce the need to void
C) Keep the patient in a supine position at all times
D) Use a catheter for continuous drainage
A nurse is assisting a patient with a history of stroke to transfer from the bed to a wheelchair. Which of the following is the most important safety precaution?
A) Allow the patient to transfer independently
B) Ensure the wheelchair is locked before the transfer
C) Ask the patient to lift themselves out of bed
D) Reposition the patient in bed before the transfer
A nurse is teaching a patient with arthritis how to manage joint pain. Which of the following should the nurse recommend to the patient to prevent further joint damage?
A) Perform high-impact exercises to strengthen the joints
B) Use assistive devices to reduce strain on the joints
C) Limit movement of the affected joints to avoid pain
D) Keep the joints in a fixed position to promote healing
A nurse is caring for a patient who has undergone spinal surgery and is immobilized in a brace. Which of the following is the priority intervention to prevent complications?
A) Encourage the patient to perform range-of-motion exercises
B) Keep the patient in a sitting position for extended periods
C) Reposition the patient every 2 hours
D) Administer sedatives to help the patient relax
A nurse is caring for an immobile patient at risk for respiratory complications. Which of the following is the most appropriate intervention?
A) Keep the patient’s head elevated at all times
B) Administer oxygen therapy regularly
C) Encourage coughing and deep breathing exercises every 2 hours
D) Limit fluid intake to prevent lung congestion
A nurse is caring for a patient who has had a recent stroke and is immobile. Which of the following should the nurse monitor for to assess for complications related to immobility?
A) Dehydration
B) Hypotension
C) Pressure ulcers
D) Hypertension
A nurse is caring for a patient who is bedridden due to a leg injury. Which of the following is the most appropriate intervention to prevent muscle atrophy?
A) Encourage passive range-of-motion exercises for the affected leg
B) Keep the patient in bed without moving for 48 hours
C) Restrict the patient’s movement to prevent further injury
D) Apply a heating pad to the affected leg to relieve stiffness
A nurse is assessing a patient for complications related to prolonged immobility. Which of the following signs should the nurse recognize as indicative of a pulmonary embolism?
A) Increased heart rate and chest pain
B) Diarrhea and dehydration
C) Elevated blood pressure and headache
D) Shortness of breath and coughing
A nurse is assisting a patient with a fractured leg. The patient is at risk for complications related to immobility. Which of the following should the nurse include in the care plan to reduce the risk of deep vein thrombosis (DVT)?
A) Encourage ambulation as soon as possible
B) Apply warm compresses to the affected leg
C) Restrict fluid intake to reduce swelling
D) Elevate the affected leg above heart level
A nurse is caring for a patient who is immobile due to a spinal cord injury. The nurse is concerned about the risk of autonomic dysreflexia. Which of the following actions should the nurse take to prevent this condition?
A) Keep the patient’s environment warm
B) Monitor the patient’s blood pressure regularly
C) Apply cold compresses to the affected area
D) Restrict fluid intake to reduce bladder distention
A nurse is assisting a patient with a lower limb amputation. Which of the following interventions should the nurse implement to promote mobility?
A) Teach the patient to use a prosthesis as soon as possible
B) Encourage the patient to remain in bed for the first 24 hours
C) Apply a compression bandage to the affected limb
D) Immobilize the residual limb for the first 48 hours
A nurse is assessing a patient for signs of dehydration while on bed rest. Which of the following is the most common sign of dehydration in an immobile patient?
A) Increased urination
B) Dry mouth and skin turgor
C) Hypotension and decreased heart rate
D) Increased appetite and thirst
A nurse is caring for a patient who has been on bed rest for several weeks. Which of the following is the most common complication associated with prolonged immobility?
A) Pressure ulcers
B) Hypertension
C) Pulmonary embolism
D) Renal failure
A nurse is providing care to an elderly patient with arthritis. Which of the following interventions is most appropriate to promote mobility and prevent joint stiffness?
A) Encourage the patient to perform weight-bearing exercises
B) Restrict movement of the affected joints
C) Provide assistive devices to aid in movement
D) Apply heat to the joints regularly
A nurse is caring for a patient with a recent hip replacement. Which of the following interventions should the nurse prioritize to prevent hip dislocation?
A) Keep the affected leg abducted
B) Allow the patient to sit with the legs crossed
C) Use a recliner to allow for full leg extension
D) Ensure the affected leg is kept in a neutral position
A nurse is caring for a patient recovering from a stroke. Which of the following is the most important nursing action to promote mobility?
A) Encourage the patient to remain in bed for the first 48 hours
B) Perform passive range-of-motion exercises for the affected limbs
C) Restrict movement of the limbs to prevent injury
D) Use a mechanical lift for all transfers
A nurse is caring for a patient with limited mobility due to chronic illness. Which of the following is an early sign of deep vein thrombosis (DVT)?
A) Pain and swelling in the affected leg
B) Bluish discoloration of the toes
C) Redness and warmth in the affected area
D) Decreased pulse in the affected limb
A nurse is assisting a patient with a hip replacement. Which of the following is the most important safety measure to prevent falls during ambulation?
A) Ensure the patient uses a walker or cane
B) Allow the patient to walk independently
C) Increase the patient’s fluid intake before ambulation
D) Keep the patient’s room dimly lit to prevent disorientation
A nurse is assessing a patient for complications related to immobility. Which of the following findings is most concerning?
A) Increased muscle tone in the affected limb
B) Difficulty in performing range-of-motion exercises
C) Swelling and redness in the lower extremities
D) Increased appetite and thirst
A nurse is teaching a patient with a spinal injury about the prevention of complications related to immobility. Which of the following interventions should the nurse include in the teaching?
A) Encourage daily ambulation
B) Keep the head of the bed elevated at all times
C) Use pressure-relieving devices to prevent skin breakdown
D) Avoid repositioning the patient to prevent further injury
A nurse is caring for a patient with limited mobility due to osteoarthritis. Which of the following interventions is most appropriate to promote joint flexibility?
A) Encourage the patient to perform range-of-motion exercises
B) Restrict movement of the joints to prevent pain
C) Provide a warm compress to the affected joints
D) Limit weight-bearing exercises to prevent injury
A nurse is caring for a patient who is immobile due to a leg fracture. Which of the following should the nurse prioritize to prevent complications?
A) Encourage fluid intake to prevent dehydration
B) Elevate the affected leg to reduce swelling
C) Apply a heating pad to the fracture site
D) Restrict the patient’s movement to prevent further injury
A nurse is caring for a patient with a spinal cord injury. Which of the following interventions is most important to prevent autonomic dysreflexia?
A) Keep the patient’s environment cool
B) Monitor the patient’s blood pressure regularly
C) Reposition the patient every 4 hours
D) Restrict fluid intake to reduce bladder distention
A nurse is providing care to a patient recovering from hip surgery. Which of the following interventions is essential to prevent dislocation of the hip joint?
A) Keep the affected leg in a neutral position
B) Allow the patient to cross their legs at the ankles
C) Keep the patient in a sitting position for long periods
D) Place the affected leg in a prone position
A nurse is caring for a patient who is at risk for falls. Which of the following interventions should be implemented first?
A) Place the patient on a low bed
B) Provide a fall risk bracelet
C) Encourage the patient to use a walker
D) Lock the wheels of the bed and wheelchair
A nurse is assessing a patient with a recent stroke and limited mobility. Which of the following interventions should the nurse prioritize to prevent complications of immobility?
A) Encourage the patient to stay in bed for 24 hours
B) Assist the patient with active range-of-motion exercises
C) Keep the patient in a supine position at all times
D) Limit the patient’s fluid intake to reduce swelling
A nurse is caring for a patient with a hip fracture. Which of the following is the most important intervention to prevent further complications from immobility?
A) Keep the patient in a flat position to prevent pressure ulcers
B) Encourage deep breathing and coughing exercises
C) Use an abdominal binder to reduce the risk of DVT
D) Apply a pressure-relieving mattress to the bed
A nurse is caring for a patient who is immobile due to a lower extremity injury. Which of the following is the priority intervention to prevent deep vein thrombosis (DVT)?
A) Encourage the patient to perform leg exercises
B) Apply compression stockings as prescribed
C) Limit fluid intake to reduce swelling
D) Keep the affected limb elevated at all times
A nurse is teaching a patient with arthritis about maintaining joint mobility. Which of the following should the nurse include in the teaching?
A) Perform joint exercises only when experiencing pain
B) Rest the affected joints and avoid movement
C) Use assistive devices to reduce strain on the joints
D) Apply ice to the joints after every exercise session
A nurse is caring for a patient who is recovering from a stroke. The patient is experiencing difficulty in moving the left arm. Which of the following interventions should the nurse implement to promote mobility?
A) Restrict the movement of the left arm to prevent further injury
B) Assist the patient with passive range-of-motion exercises
C) Encourage the patient to remain in bed to promote healing
D) Use a splint to keep the left arm in a fixed position
A nurse is assisting a patient who has been on prolonged bed rest. Which of the following is an early sign of deep vein thrombosis (DVT)?
A) Calf pain, redness, and swelling
B) Pain and swelling in the abdomen
C) Chest pain and shortness of breath
D) Pitting edema in the lower extremities
A nurse is teaching a patient recovering from knee surgery about mobility restrictions. Which of the following should the nurse include in the teaching plan?
A) Ambulate as soon as possible to prevent muscle weakness
B) Avoid bearing weight on the affected leg until cleared by the physician
C) Perform weight-bearing exercises as tolerated
D) Remain in bed for at least 2 weeks to allow healing
A nurse is assessing a patient who is immobile due to a spinal cord injury. Which of the following is the most important to prevent complications from immobility?
A) Administer stool softeners as prescribed
B) Encourage the patient to engage in activities of daily living
C) Provide a high-fiber diet and adequate fluid intake
D) Keep the patient in the same position to promote rest
A nurse is caring for a patient recovering from a lower limb amputation. Which of the following should the nurse prioritize to enhance mobility?
A) Encourage the use of a prosthetic limb as soon as possible
B) Allow the patient to remain immobile for 2 weeks for healing
C) Apply a compression bandage to the residual limb as prescribed
D) Perform passive range-of-motion exercises for the unaffected limb
A nurse is caring for a patient who has undergone a hip replacement. Which of the following actions is essential to prevent complications from immobility?
A) Encourage early ambulation with the use of assistive devices
B) Allow the patient to sit with the legs crossed to improve comfort
C) Apply a heat pad to the hip joint to prevent stiffness
D) Keep the patient in a reclined position for extended periods
A nurse is caring for an elderly patient with limited mobility due to arthritis. Which of the following should the nurse prioritize to prevent complications of immobility?
A) Encourage ambulation at least twice a day
B) Limit the patient’s fluid intake to reduce swelling
C) Assist the patient with active range-of-motion exercises
D) Restrict movement of the affected joints to prevent pain
A nurse is caring for a patient who is recovering from a stroke and is unable to move the left arm. Which of the following interventions should the nurse implement to prevent complications related to immobility?
A) Apply a splint to the affected arm to prevent deformities
B) Keep the left arm elevated to reduce swelling
C) Perform passive range-of-motion exercises for the left arm
D) Encourage the patient to rest the arm for 48 hours
A nurse is caring for a patient with a leg fracture. Which of the following is the most appropriate intervention to prevent muscle atrophy?
A) Encourage the patient to perform passive range-of-motion exercises
B) Restrict movement of the affected leg to promote healing
C) Apply ice to the fracture site to reduce swelling
D) Provide frequent massages to the affected limb
A nurse is caring for a patient who is immobile due to a hip fracture. Which of the following is the most important to monitor for complications related to immobility?
A) Skin breakdown
B) Increased appetite
C) Decreased urine output
D) Increased muscle strength
A nurse is assisting a patient with a spinal cord injury. Which of the following interventions should the nurse prioritize to promote mobility?
A) Restrict movement of the limbs to prevent injury
B) Assist the patient with range-of-motion exercises
C) Allow the patient to remain in bed for the first 48 hours
D) Use a mechanical lift for all transfers
A nurse is caring for a patient with arthritis. Which of the following interventions is most appropriate to reduce joint pain and stiffness?
A) Apply heat to the affected joints
B) Rest the joints in a fixed position
C) Avoid all weight-bearing activities
D) Increase fluid intake to promote joint lubrication
A nurse is teaching a patient recovering from surgery about the importance of early ambulation. Which of the following should the nurse include in the teaching?
A) Early ambulation reduces the risk of deep vein thrombosis (DVT)
B) Early ambulation increases the risk of wound dehiscence
C) Early ambulation promotes muscle weakness
D) Early ambulation is contraindicated for most surgeries
A nurse is providing care for a patient recovering from a lower limb amputation. Which of the following is the priority intervention to prevent complications from immobility?
A) Keep the patient in a supine position for 1 hour a day
B) Assist the patient with weight-bearing activities as soon as possible
C) Apply a prosthetic limb immediately after surgery
D) Encourage the patient to engage in upper body exercises
A nurse is caring for a patient who is at risk for developing deep vein thrombosis (DVT) due to immobility. Which of the following interventions is the most effective for prevention?
A) Position the patient in a Trendelenburg position
B) Administer anticoagulants as prescribed
C) Keep the patient in a prone position
D) Apply a cold compress to the legs
A nurse is assisting a patient with mobility after hip replacement surgery. Which of the following actions should the nurse avoid?
A) Reposition the patient every 2 hours
B) Encourage the patient to perform active range-of-motion exercises
C) Allow the patient to cross their legs at the ankles
D) Elevate the affected leg when sitting
A nurse is caring for a patient who is recovering from a stroke and has limited mobility on one side. Which of the following interventions should the nurse prioritize?
A) Reposition the patient every 6 hours
B) Perform passive range-of-motion exercises on the affected side
C) Restrict movement of the affected side to prevent injury
D) Allow the patient to remain in a single position for comfort
A nurse is caring for a patient with a leg fracture and is at risk for muscle atrophy due to immobility. Which of the following actions should the nurse take to prevent muscle atrophy?
A) Encourage the patient to perform active range-of-motion exercises
B) Apply heat to the affected area
C) Keep the patient on bed rest for the first 24 hours
D) Avoid moving the affected leg
A nurse is caring for a patient who has undergone knee surgery and is experiencing pain with movement. Which of the following interventions should the nurse implement to facilitate mobility?
A) Administer pain medication as prescribed before moving the patient
B) Restrict the patient to bed rest to reduce discomfort
C) Perform passive range-of-motion exercises only when the patient is asleep
D) Limit the patient’s fluid intake to prevent swelling
A nurse is caring for a patient with a recent hip replacement. Which of the following is essential to prevent dislocation of the hip joint during recovery?
A) Keep the affected leg in a neutral position at all times
B) Allow the patient to bend the hip at an angle greater than 90 degrees
C) Encourage the patient to sit on soft chairs
D) Allow the patient to cross their legs at the knees
A nurse is caring for a patient who is immobile due to a spinal cord injury. Which of the following should the nurse include in the plan of care to prevent complications of immobility?
A) Reposition the patient every 8 hours
B) Provide a high-calcium diet to strengthen bones
C) Encourage the patient to sit up in a chair for 30 minutes every day
D) Perform passive range-of-motion exercises every 24 hours
A nurse is teaching a patient with arthritis about maintaining joint mobility. Which of the following should the nurse include in the teaching?
A) Avoid any exercise that causes pain in the joints
B) Perform range-of-motion exercises 3 times a week
C) Use heat therapy to reduce stiffness in the morning
D) Limit the use of assistive devices to encourage strength
A nurse is providing care to a patient who is at risk for developing pressure ulcers due to immobility. Which of the following interventions is most effective in preventing pressure ulcers?
A) Reposition the patient every 4 hours
B) Use a high-protein diet to promote healing
C) Ensure the patient has adequate hydration
D) Keep the patient in a seated position for most of the day
A nurse is caring for a patient who is recovering from a lower limb amputation. The nurse should encourage the patient to do which of the following to promote mobility?
A) Use a prosthetic limb as soon as possible after surgery
B) Stay in bed until the wound has completely healed
C) Perform passive range-of-motion exercises twice a day
D) Apply a compression bandage to the residual limb after each activity
A nurse is caring for a patient with a leg fracture. The nurse is concerned about the development of deep vein thrombosis (DVT). Which of the following is the most effective intervention to prevent DVT?
A) Elevate the leg above the heart level
B) Apply compression stockings as prescribed
C) Perform passive range-of-motion exercises
D) Administer anticoagulants as prescribed
A nurse is teaching a patient with limited mobility due to hip arthritis how to use assistive devices. Which of the following should the nurse include in the teaching?
A) Always use a walker while standing to reduce pressure on the joints
B) Use a cane in the opposite hand of the affected leg to provide balance
C) Use a wheelchair for all activities to avoid strain on the joints
D) Place the walker in front of the body to encourage faster ambulation
A nurse is caring for a patient with limited mobility after knee surgery. Which of the following interventions should the nurse implement to prevent muscle atrophy?
A) Encourage the patient to remain in bed until the wound heals
B) Perform passive range-of-motion exercises every 2 hours
C) Provide frequent rest periods and immobilization of the leg
D) Apply heat to the affected joint to improve circulation
A nurse is assessing a patient who is at risk for falls due to immobility. Which of the following should the nurse prioritize in the plan of care?
A) Teach the patient how to ambulate with assistive devices
B) Encourage the patient to remain in bed as much as possible
C) Limit the patient’s fluid intake to reduce the risk of falls
D) Use restraints to prevent the patient from getting out of bed
A nurse is caring for a patient with spinal cord injury who is experiencing autonomic dysreflexia. Which of the following is the priority intervention?
A) Administer antihypertensive medication
B) Sit the patient upright to lower blood pressure
C) Reposition the patient in a flat, supine position
D) Remove any noxious stimuli, such as a full bladder or tight clothing
A nurse is assisting a patient recovering from a stroke with mobility exercises. Which of the following interventions is most important to prevent complications of immobility?
A) Encourage early mobilization and use of assistive devices
B) Keep the patient in a flat, supine position for the first 24 hours
C) Provide a high-protein, low-sodium diet to reduce swelling
D) Perform passive range-of-motion exercises every 6 hours
A nurse is caring for a patient with chronic immobility due to osteoarthritis. Which of the following interventions should the nurse prioritize to maintain mobility?
A) Perform passive range-of-motion exercises twice a day
B) Teach the patient how to use a walker to reduce joint strain
C) Apply heat and cold therapy alternately to the affected joints
D) Restrict all weight-bearing activities to prevent joint damage
A nurse is teaching a patient who is immobile due to a recent fracture how to prevent muscle atrophy. Which of the following should the nurse include in the teaching?
A) Perform active range-of-motion exercises as tolerated
B) Limit movement of the affected limb to promote healing
C) Use a sling to immobilize the affected area for 4 weeks
D) Apply heat to the muscles to improve flexibility
A nurse is caring for a patient with a recent leg fracture. Which of the following interventions is most effective in preventing the complications of immobility?
A) Encourage early ambulation with the use of a walker
B) Keep the affected leg in a dependent position
C) Provide a high-fiber diet to prevent constipation
D) Limit fluid intake to reduce swelling
A nurse is assisting a patient who has been immobile for several days. Which of the following actions will best help prevent pulmonary complications?
A) Encourage the patient to cough and deep breathe every hour
B) Restrict fluid intake to prevent congestion
C) Administer oxygen as prescribed
D) Place the patient in a supine position
A nurse is caring for a patient who has a cast on their leg due to a fracture. Which of the following actions should the nurse take to prevent complications associated with immobility?
A) Elevate the casted leg above the heart level
B) Perform passive range-of-motion exercises to the unaffected leg
C) Apply a heating pad to the casted leg to reduce swelling
D) Limit fluid intake to reduce edema
A nurse is caring for a patient who has undergone a hip replacement. Which of the following interventions should the nurse include in the plan of care to prevent dislocation of the new joint?
A) Avoid placing pillows under the affected leg
B) Instruct the patient to avoid crossing their legs
C) Encourage the patient to sit on soft chairs
D) Restrict the patient from moving their affected leg for 24 hours
A nurse is caring for a patient with a spinal cord injury. Which of the following actions is most effective in preventing pressure ulcers?
A) Reposition the patient every 2 hours
B) Keep the patient in one position for 6 hours
C) Apply a topical antibiotic to the skin daily
D) Use a pressure-relieving mattress
A nurse is providing care to a patient who is immobilized due to a leg fracture. Which of the following interventions should the nurse prioritize to reduce the risk of deep vein thrombosis (DVT)?
A) Encourage the patient to perform active range-of-motion exercises
B) Elevate the affected leg above the heart level
C) Apply compression stockings as prescribed
D) Keep the patient on complete bed rest
A nurse is assessing a patient who has been immobile due to a stroke. The nurse observes that the patient has a decreased ability to move one side of the body. Which of the following interventions is most important to prevent complications of immobility?
A) Perform passive range-of-motion exercises on the affected side
B) Encourage the patient to rest in a side-lying position
C) Reposition the patient every 8 hours
D) Apply a splint to the affected arm
A nurse is caring for a patient who has recently had surgery for a hip fracture. Which of the following interventions should the nurse implement to reduce the risk of complications related to immobility?
A) Limit movement of the affected leg
B) Administer pain medication before mobilizing the patient
C) Apply a cold compress to the affected leg
D) Keep the affected leg elevated above the heart level
A nurse is teaching a patient who is recovering from a spinal cord injury about ways to prevent complications of immobility. Which of the following should the nurse include in the teaching?
A) Avoid repositioning to reduce strain on the body
B) Limit fluid intake to decrease the need for repositioning
C) Perform passive range-of-motion exercises regularly
D) Remain in a supine position to prevent pressure ulcers
A nurse is caring for a patient who is recovering from a lower extremity amputation. Which of the following interventions is most important to help the patient regain mobility?
A) Keep the patient on bed rest for 24 hours after surgery
B) Assist the patient with walking using a prosthetic limb as soon as possible
C) Keep the stump elevated for the first 48 hours
D) Apply a compression bandage to the stump immediately after surgery
A nurse is caring for a patient who is at risk for developing contractures due to immobility. Which of the following interventions should the nurse implement to prevent contractures?
A) Perform range-of-motion exercises every 2 hours
B) Limit the patient’s movement to prevent muscle strain
C) Place pillows under the patient’s joints to maintain their position
D) Apply a hot compress to the affected joints
A nurse is providing discharge teaching to a patient with arthritis to promote mobility. Which of the following instructions should the nurse include?
A) Use a cane on the side of the unaffected leg
B) Perform weight-bearing exercises to strengthen joints
C) Limit the use of assistive devices to encourage muscle strength
D) Apply ice to the joints after physical activity
A nurse is caring for a patient who is immobile due to a fractured leg. Which of the following interventions is most effective in preventing urinary retention?
A) Encourage fluid intake of at least 2 liters per day
B) Position the patient in a lateral position
C) Offer frequent bedpans every hour
D) Limit the patient’s intake of high-sodium foods
A nurse is caring for a patient who is immobile due to severe osteoarthritis. The patient reports significant pain with movement. Which of the following interventions should the nurse implement first?
A) Provide pain medication 30 minutes before assisting with movement
B) Use heat therapy to alleviate stiffness
C) Reposition the patient every 4 hours
D) Apply a cold compress to the joints
A nurse is caring for a patient with limited mobility following a stroke. Which of the following interventions is most important for preventing complications of immobility?
A) Perform passive range-of-motion exercises on the affected side
B) Keep the affected limb in a neutral position
C) Limit the patient’s activity to prevent overexertion
D) Position the patient in a supine position for 6 hours per day
A nurse is teaching a patient with chronic pain about the use of mobility aids. Which of the following should the nurse include in the teaching?
A) Use a walker on the affected side to provide better support
B) Ensure the walker is adjusted to the correct height to prevent strain
C) Limit the use of the walker to short distances
D) Apply a cold compress to the hands before using the walker
A nurse is caring for a patient who has a non-weight-bearing leg fracture. Which of the following interventions is most important to prevent complications of immobility?
A) Assist the patient in performing active range-of-motion exercises
B) Keep the affected leg elevated to reduce swelling
C) Encourage the patient to stay in bed for most of the day
D) Provide frequent rest periods to prevent muscle strain
A nurse is caring for a patient with limited mobility following a knee replacement. Which of the following interventions should the nurse implement to prevent complications of immobility?
A) Assist the patient with ambulation as soon as possible
B) Keep the knee in a fixed position to allow for healing
C) Limit physical activity for the first 24 hours
D) Apply heat to the knee to reduce swelling
A nurse is caring for a patient with a leg injury who is immobile. The nurse should assess for which of the following complications?
A) Increased muscle strength
B) Increased blood pressure
C) Decreased bowel function
D) Increased circulation in the affected limb
A nurse is caring for a patient with a hip fracture. Which of the following interventions should the nurse prioritize to reduce the risk of complications?
A) Keep the affected hip in a fixed position for 48 hours
B) Encourage the patient to perform weight-bearing activities immediately
C) Use a pillow to maintain abduction of the hip
D) Apply cold compresses to reduce swelling
A nurse is caring for a patient with a leg cast. Which of the following is the most important intervention to promote circulation in the affected limb?
A) Elevate the leg above the heart level
B) Apply ice to the affected limb
C) Keep the casted leg in a dependent position
D) Perform active range-of-motion exercises on the unaffected leg
Questions and Answers for Study Guide
Discuss the nursing interventions that are essential for preventing complications related to immobility in a patient who has undergone hip replacement surgery.
Answer:
Following hip replacement surgery, patients are at risk for various complications due to immobility. Effective nursing interventions aim to prevent these complications, enhance recovery, and promote mobility. The primary interventions include:
- Pain Management: Pain relief is crucial for promoting early mobility. Administering pain medications as prescribed and ensuring that the patient can perform activities such as deep breathing, coughing, and range-of-motion exercises with minimal discomfort will facilitate recovery.
- Mobility and Positioning: Early mobilization is essential to prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism. Nurses should assist patients with standing and walking as soon as medically appropriate, while also teaching the patient to use assistive devices, like walkers or canes, to promote safety and mobility. Proper positioning of the affected leg, such as using abduction pillows or ensuring neutral hip positioning, helps prevent dislocation of the new joint.
- Preventing Pressure Ulcers: Prolonged immobility increases the risk of pressure ulcers. Repositioning the patient every two hours and utilizing pressure-relieving mattresses or cushions are vital interventions to reduce pressure on bony prominences.
- Respiratory Health: Encouraging deep breathing and coughing exercises every hour helps to prevent respiratory complications like atelectasis and pneumonia, which are more likely to occur with immobility. Incentive spirometry can also be used to promote lung expansion and oxygenation.
- Circulation: To prevent DVT, nurses should encourage the use of compression stockings, administer anticoagulant medications as prescribed, and assist with range-of-motion exercises to promote venous return.
These interventions collectively improve the patient’s mobility, prevent complications, and accelerate recovery following hip replacement surgery.
Describe the impact of immobility on a patient’s musculoskeletal system and the nursing interventions to mitigate these effects.
Answer:
Immobility leads to several significant changes in the musculoskeletal system, which can affect the patient’s overall health and ability to regain function. The primary effects include:
- Muscle Atrophy: Prolonged immobility causes muscle disuse, leading to muscle weakness and atrophy. This results in decreased strength, endurance, and range of motion (ROM).
- Joint Stiffness and Contractures: Joint stiffness and the formation of contractures occur due to the lack of movement and stretching of muscles and ligaments. This can lead to permanent deformities if not addressed.
- Decreased Bone Density: Immobilization leads to bone resorption and decreased bone density, increasing the risk of fractures. This phenomenon is especially common in individuals who have been immobile for extended periods, such as those on bed rest or with spinal cord injuries.
- Postural and Gait Abnormalities: Prolonged immobility can alter the alignment and posture of the body, leading to compensatory mechanisms that result in abnormal gait patterns. These abnormalities can hinder a patient’s ability to return to normal movement.
Nursing interventions to mitigate these effects include:
- Range-of-Motion (ROM) Exercises: Encouraging or performing passive and active ROM exercises is essential to maintain joint flexibility and prevent contractures. ROM exercises can be done at least twice a day to preserve muscle tone and joint function.
- Positioning: Proper positioning in bed is essential to prevent deformities. For example, placing pillows or foam wedges under the joints to maintain proper alignment can help prevent contractures.
- Weight-Bearing Activities: Whenever possible, assisting patients with partial weight-bearing or full weight-bearing activities can help promote bone density. Early ambulation is key to preventing bone loss, as well as encouraging the use of assistive devices to improve mobility and balance.
- Muscle Strengthening Exercises: Encouraging the patient to perform strengthening exercises can help prevent muscle atrophy. Nurses can assist with exercises tailored to the patient’s ability, gradually increasing resistance as tolerated.
These interventions are critical in preserving musculoskeletal function, preventing complications, and improving the patient’s chances of regaining independence.
Explain the psychological effects of immobility on a patient and the role of nursing interventions in addressing these effects.
Answer:
Immobility can have profound psychological effects on patients, impacting their mental and emotional well-being. Some of the most common psychological effects include:
- Depression and Anxiety: Patients experiencing immobility may become frustrated, isolated, and overwhelmed by the physical limitations they face. This can lead to feelings of sadness, helplessness, and anxiety. Fear of permanent disability and the loss of independence can exacerbate these feelings.
- Decreased Self-Esteem: Immobility often leads to a loss of autonomy and an inability to perform activities of daily living (ADLs). This can cause patients to feel inadequate, leading to lowered self-esteem and feelings of worthlessness.
- Social Isolation: Prolonged immobility may limit a patient’s ability to interact with family, friends, or peers. This isolation can result in loneliness and further worsen the psychological burden of immobility.
- Cognitive Decline: Extended immobility, especially in elderly patients, can lead to cognitive decline, such as confusion, disorientation, and delirium. The lack of stimulation from normal activities can affect cognitive function and mental clarity.
Nursing interventions to address these psychological effects include:
- Encouraging Communication: Actively engaging with the patient and encouraging open communication about their feelings is essential. Nurses should listen attentively to the patient’s concerns and provide emotional support, helping to alleviate anxiety and feelings of isolation.
- Promoting Social Interaction: Nurses should encourage family visits, phone calls, or participation in group activities to reduce social isolation. This helps the patient feel connected and supported.
- Providing Psychological Support: Providing information about the patient’s condition and recovery process can help reduce anxiety. Referring the patient to a counselor or psychologist for additional emotional support may be necessary.
- Encouraging Participation in ADLs: Even when a patient is immobile, encouraging them to participate in simple activities like grooming or dressing, if feasible, can promote a sense of accomplishment and maintain dignity.
By addressing the psychological impacts of immobility, nurses help improve the patient’s emotional well-being and enhance their overall recovery.
What are the complications associated with immobility, and what nursing interventions can prevent these complications in critically ill patients?
Answer:
Immobility in critically ill patients can lead to a variety of complications that affect multiple systems in the body. Common complications include:
- Pressure Ulcers: Prolonged pressure on the skin, particularly over bony prominences, can lead to skin breakdown and pressure ulcers. These ulcers can result in infection and delayed recovery.
- Deep Vein Thrombosis (DVT) and Pulmonary Embolism: Immobility decreases venous return and promotes blood clot formation in the lower extremities, increasing the risk of DVT. A clot can travel to the lungs, causing a pulmonary embolism, which is a life-threatening condition.
- Pneumonia and Atelectasis: Immobility leads to poor lung expansion, which can increase the risk of atelectasis (collapse of the lung) and pneumonia. The lack of coughing and deep breathing contributes to poor clearance of respiratory secretions.
- Urinary Retention and Constipation: The lack of movement and changes in fluid intake may lead to urinary retention and constipation, both of which can result in discomfort and increased risk of infection.
- Musculoskeletal Complications: As discussed earlier, immobility can lead to muscle atrophy, joint stiffness, and decreased bone density.
Nursing interventions to prevent these complications include:
- Repositioning: Repositioning the patient every two hours reduces the risk of pressure ulcers. Using pressure-relieving devices such as specialized mattresses and cushions further decreases pressure on vulnerable areas.
- Encouraging Mobilization: As soon as medically appropriate, encouraging early ambulation and using devices such as compression stockings can help prevent DVT and improve circulation. Administering prescribed anticoagulants can further reduce the risk of clot formation.
- Respiratory Care: Nurses should encourage coughing and deep breathing exercises every hour and use incentive spirometry to promote lung expansion. Suctioning and chest physiotherapy may be required for patients unable to clear their airways effectively.
- Bowel and Bladder Care: Ensuring adequate fluid intake, providing a diet high in fiber, and administering stool softeners or laxatives as needed help prevent constipation. Monitoring urinary output and encouraging voiding at regular intervals reduces the risk of urinary retention.
By implementing these interventions, nurses can help prevent the common complications associated with immobility and promote the patient’s overall recovery.