A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, then relax.

Move the client's limbs through their complete range of motion.

Ask the client to move her arms and legs while applying slight resistance.

Have the client move each limb independently through its complete range of motion.

Answer and Explanation

The Correct Answer is A

A.   Isometric exercises involve contracting or tensing muscles without actually moving the joint. Instructing the client to tighten muscle groups for a short period and then relax is the correct approach for isometric exercises. This action helps activate and strengthen specific muscle groups without moving the joints.
B.   Moving the client's limbs through their complete range of motion is known as passive range of motion exercises. These exercises are important for maintaining joint flexibility but are not isometric.
C.   Asking the client to move her arms and legs while applying slight resistance is known as resisted range of motion exercises. These exercises involve active movement against resistance and are not considered isometric.
D.   Having the client move each limb independently through its complete range of motion is known as active range of motion exercises. These exercises involve voluntary
movement of each joint through its full range of motion and is not isometric.

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Correct Answer is A

Explanation

A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

A. Wash the client's extremities from proximal to distal. B. Check for personal items when changing the bed linens. C. Shave the client's hair in the direction of the hair growth. D. Place a clean gown on the strongest arm first. E. Keep the bath water temperature between between 43.3 C (110F) and 46.1 C (115F)

Correct Answer is ["B","C","E"]

Explanation

A. Washing the client's extremities from proximal to distal is a good practice, but it is not specifically related to caring for an immobile client.
B. Checking for personal items when changing the bed linens is important to ensure that the client's belongings are not lost or misplaced during the process.
C. Shaving the client's hair in the direction of hair growth helps prevent skin irritation and ingrown hairs.
D. The gown should be placed on the weaker arm first.
E. This is an appropriate temperature that can help client remain comfortable.

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A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Nursing Test Bank

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