A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Move body parts rapidly through the movements.

Support extremities above and below joints.

Continue moving body parts if muscle spasticity occurs.

Stretch the body part just beyond the existing range of motion.

Answer and Explanation

The Correct Answer is B

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

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Correct Answer is C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

A. Absent B. Blowing sound due to restriction. C. A continuous medium pitched sound. D. High pitched, tinkling, rushing or growling.

Correct Answer is D

Explanation

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

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Correct Answer is D

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