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","C","D","E"]
Explanation
A. Mr. Milby states his pain level is a 0/10
This indicates good pain control, which is expected and desired postoperatively.
B. Head of bed is elevated 45 degrees
Elevation this high may cause improper alignment and interfere with the machine’s function. Typically, HOB should be no more than 20-30 degrees during CPM use.
C. Mr. Milby complains of "tightness" of incision when CPM machine is at maximum flexion
This could indicate excessive tension on the wound or early signs of complications like swelling or dehiscence.
D. All side rails on Mr. Milby’s bed are down
This is a safety hazard. At least one or two side rails should be up during machine use to prevent falls.
E. The knee dressing is loose and not adhering on all sides
Loose dressings may indicate poor wound protection and risk for infection or wound exposure.
F. The machine is set to 45 degrees of flexion
This is per the physician’s order and indicates proper settings.
Correct Answer is B
Explanation
A. Take off the rubber tips of the crutches while using stairs.
Rubber tips provide traction and prevent slipping; they must remain in place.
B. Bring the good leg up first when going up stairs.
The mnemonic “Up with the good, down with the bad” applies here. The stronger leg goes up first for stability.
C. Move the good leg and the crutches together.
Crutches move with the affected (bad) leg, not the good one.
D. Rest the axillae on the axillary bar of the crutch.
This can compress nerves and blood vessels. Weight should rest on the hand grips, not underarms.
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