A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?
Develops fatigue when assisting with morning hygiene care
Needs assistance raising her legs to put on socks
Performs active range-of-motion (ROM) exercises of all extremities
Demonstrates mild dyspnea when eating breakfast
The Correct Answer is C
A. Develops fatigue when assisting with morning hygiene care
Fatigue during hygiene suggests low endurance; not ready to ambulate safely.
B. Needs assistance raising her legs to put on socks
Needing assistance for simple tasks shows weakness and poor muscle control.
C. Performs active range-of-motion (ROM) exercises of all extremities
Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.
D. Demonstrates mild dyspnea when eating breakfast
Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Using the spreader bar to turn the patient.
The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.
B. Protecting the cast from soiling.
Soiling the cast can lead to skin irritation and infection, especially in the perineal area.
C. Grasping the cast over the leg to help in turning.
This can cause pressure points or cast damage; turning should be done using proper support techniques.
D. Easing itching under the cast by scratching with a bent coat hanger.
This is unsafe and can cause skin injury or infection under the cast.
E. Turning frequently to the prone position.
Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.
Correct Answer is B
Explanation
A. maintaining strength in muscles.
This is a benefit of ROM exercises, but it does not directly explain how venous return improves.
B. compression of muscles on venous walls.
Muscle contraction compresses veins, helping to push blood back toward the heart, improving venous return.
C. vasodilation.
Vasodilation increases blood flow, but doesn’t directly enhance venous return in the context of ROM.
D. increased metabolism.
Increased metabolism is a systemic benefit of exercise but is not the primary mechanism of improved venous circulation.
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