A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
a. Nutritional intake and serum albumin levels
b. Pressure ulcer diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application
Question 2A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
a. Splint the joint and continue passive range of motion to the shoulder only.
b. Progressively increase joint motion 5 degrees beyond resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Continue to move the joint only to the point at which resistance is met.
Question 3A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
a. Use analgesics before and after activity, even if you are not experiencing pain.
b. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
c. Do not take your prescribed beta blocker until after you exercise with physical therapy.
d. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Question 4A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach?
a. Use the bear-hug method to transfer the client safely.
b. Ask several members of the health care team to carry the client.
c. Utilize the facility's mechanical lift to move the client.
d. Consult physical therapy before performing all transfers.
Question 5A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity tolerance?
a. Vital signs before, during, and after activity
b. Body image and self-care abilities
c. Ability to use assistive or adaptive devices
d. Client's electrocardiography readings
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