NCLEX-PN Test #16 1 — Questions and Answers
Question 1: A nurse is assisting a patient with left-sided weakness to ambulate using a cane. How should the nurse instruct the patient to position the cane?
- Hold the cane on the left (weak) side
- Hold the cane on the right (strong) side (Correct answer)
- Switch the cane to whichever side feels more comfortable
- Use the cane only when going up stairs
Correct answer: Hold the cane on the right (strong) side
A cane should be held on the stronger side to provide a wide base of support and reduce weight-bearing on the weaker extremity. When walking, the patient advances the cane and the weak leg simultaneously, then brings the strong leg forward.
Question 2: A nurse is transferring an immobile patient from the bed to a wheelchair using a gait belt. What is the most important action before initiating the transfer?
- Lock the wheelchair wheels (Correct answer)
- Remove the patient's footrests
- Ensure the nurse's back is straight with feet shoulder-width apart
- Raise the bed to its highest position
Correct answer: Lock the wheelchair wheels
Locking the wheelchair wheels is the priority safety action before transferring a patient. An unlocked wheelchair can roll, causing the patient to fall. Proper body mechanics for the nurse and patient preparation are also important, but immobilizing the wheelchair comes first.
Question 3: A nurse is caring for a patient on bed rest. Which intervention is most important to prevent deep vein thrombosis (DVT)?
- Encourage the patient to flex and extend the ankles every 1–2 hours (Correct answer)
- Keep the patient's legs crossed at the ankles while in bed
- Position the patient in a prone position for most of the day
- Apply ice packs to the lower extremities every 4 hours
Correct answer: Encourage the patient to flex and extend the ankles every 1–2 hours
Active ankle flexion and extension (ankle pumps) promotes venous return from the lower extremities, reducing the risk of DVT in immobile patients. Crossing the legs compresses blood vessels and increases DVT risk. Sequential compression devices and anticoagulants may also be prescribed.
Question 4: A nurse is caring for an older adult patient who has been assessed as a fall risk. Which intervention should the nurse prioritize?
- Apply a vest restraint to keep the patient in bed
- Keep all four side rails raised at all times
- Ensure call light is within reach and bed is in lowest position (Correct answer)
- Limit fluid intake to reduce nighttime urination
Correct answer: Ensure call light is within reach and bed is in lowest position
Keeping the call light within reach and lowering the bed reduces fall risk without restraining the patient. Restraints increase fall-related injury risk and require a physician order. Raising all four side rails constitutes a restraint. Limiting fluids can worsen dehydration and increases urinary urgency when fluids are taken.
Question 5: A nurse is preparing to perform range-of-motion (ROM) exercises for a patient with contractures. Which approach is correct?
- Move each joint rapidly through its full range to stretch the contracture
- Move each joint slowly and smoothly to the point of resistance, not beyond (Correct answer)
- Perform ROM only on unaffected joints
- Apply forceful pressure past the point of resistance to break up adhesions
Correct answer: Move each joint slowly and smoothly to the point of resistance, not beyond
ROM exercises should move joints slowly and smoothly to the point of resistance — forcing beyond this can tear soft tissue and cause pain or injury. The goal is to maintain mobility and prevent worsening contracture, not to forcefully reverse existing contractures.
Question 6: A post-operative patient on the first day after total hip replacement needs to use the toilet. Which action by the nurse is most important?
- Allow the patient to squat on a standard-height toilet
- Ensure a raised toilet seat is in place to prevent hip flexion beyond 90 degrees (Correct answer)
- Assist the patient to cross the operative leg over the other for support
- Position the patient with the operative leg internally rotated
Correct answer: Ensure a raised toilet seat is in place to prevent hip flexion beyond 90 degrees
After total hip replacement, hip precautions include avoiding hip flexion beyond 90 degrees to prevent prosthesis dislocation. A raised toilet seat reduces the degree of hip flexion required when sitting. Internal rotation and crossing the legs are also contraindicated.
NCLEX-PN Test #16 1
A nurse is assisting a patient with left-sided weakness to ambulate using a cane.
How should the nurse instruct the patient to position the cane?