A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?

Atelectasis

Joint contractures

Pressure ulcers

Renal calculi

Answer and Explanation

The Correct Answer is B

A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.

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Correct Answer is C

Explanation

A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.
B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.
C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.
D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.

A. "Atelectasis affects only those with chronic conditions such as emphysema." B. "Hyperventilation will open up my alveoli, preventing atelectasis." C. "It is important to do breathing exercises every hour to prevent atelectasis." D. "If I develop atelectasis, I will need a chest tube to drain excess fluid."

Correct Answer is C

Explanation

A. Atelectasis can occur in anyone, not just those with chronic conditions; this statement is incorrect.
B. While hyperventilation may temporarily open alveoli, it is not a preventative measure for atelectasis.
C. Breathing exercises, such as incentive spirometry or deep breathing, are effective in preventing atelectasis by promoting lung expansion and alveolar ventilation.
D. A chest tube is typically used to remove air or fluid from the pleural space, not for the treatment of atelectasis, which is often managed with respiratory therapies.

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A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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