NCLEX-Style Test: Body Mechanics & Mobility CHAPTER 8 #1

A nurse prepares to reposition a patient with limited mobility who has a sacral pressure ulcer. Which action is most important to prevent worsening of the ulcer?

• Use the Trendelenburg position to improve circulation

• Place a pillow under the abdomen to offload pressure

• Slide the patient up in bed without assistance

• Position the patient on the back with knees flexed

The nurse is caring for an immobile patient with confusion and weakness. What is the nurse’s best strategy to reduce the risk of injury during a transfer to a chair?

• Instruct the patient to transfer independently

• Ask for assistance and use a transfer (draw) sheet

• Pull the patient by the arms toward the chair

• Place a gait belt loosely around the waist

A patient recovering from a stroke shows signs of external rotation of the leg. What device should the nurse use to promote correct alignment and prevent complications?

• Bed board

• Trochanter roll

• Pillow under the knee

• Trapeze bar

While repositioning an unconscious patient, the nurse notices skin blanching over the coccyx. What is the most appropriate action?

• Turn the patient to a different position and reassess skin

• Massage the reddened area to restore circulation

• Document as normal and continue care

• Apply cold compresses to the coccyx

A nurse is planning care for a patient with a high fall risk and limited sensation in the lower extremities. Which intervention best minimizes risk during ambulation?

• Instruct the patient to call for help after walking

• Encourage the patient to ambulate alone to build strength

• Walk closely behind with a gait belt and monitor footing

• Let the patient ambulate to tolerance

The nurse is caring for a bedridden patient who reports dizziness when sitting up. What is the most appropriate initial intervention?

• Return the patient to supine position immediately

• Assist the patient to sit up slowly and dangle legs

• Encourage fluid intake immediately

• Ambulate the patient to restore blood flow

During ROM exercises, a patient grimaces and reports joint pain. What should the nurse do next?

• Continue the exercise to improve flexibility

• Stop all exercises until the physician is notified

• Discontinue the movement and reassess the joint

• Apply a warm compress and retry in 5 minutes

A nurse observes a student improperly lifting a patient without bending their knees. What is the priority teaching point?

• Bend your knees and keep your back straight to avoid injury.

• Use a sliding board next time instead.

• Try holding the patient tighter.

• Avoid lifting patients during the shift.

A nurse identifies that a patient is developing a flexion contracture in the wrist. Which intervention is most appropriate?

• Apply a hand roll and reassess daily

• Place a pillow under the wrist

• Encourage the patient to use a trapeze bar

• Wrap the hand in gauze

The nurse is reviewing a care plan for a patient on bed rest. Which intervention addresses the risk of orthostatic hypotension?

• Elevate the head of the bed to 90° continuously

• Encourage slow position changes from lying to sitting

• Provide supplemental oxygen during position changes

• Encourage deep breathing before ambulating