Question 14
Type: MCSA
The client who is unconscious is developing foot drop. What nursing action is indicated?
1. Place high-topped shoes on the client while in bed.
2. Keep the linens on the end of the bed turned back to expose the feet.
3. Use only the prone and Sims positions for client positioning.
4. Use a device to elevate the linens off the feet.
Question 15
Type: MCMA
The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the
assistive personnel who will be caring for this client?
Standard Text: Select all that apply.
1. Place a turn sheet on the bed.
2. Always use two personnel to move the client.
3. Stand at the head of the bed to pull the client up.
4. Slide the client toward the head of the bed.
5. Encourage the client to assist as possible.
Question 16
Type: MCSA
The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse
take first?
1. Perform hand hygiene.
2. Move the client to the side of the bed.
3. Place the client’s arm over the chest.
4. Raise the opposite side rail.
Question 17
Type: MCSA
When planning care, the nurse should identify which client as needing logrolling for position changes?
1. A client with documented pneumonia
2. The client who has had abdominal surgery
3. The client who fell from a house, sustaining a fractured tibia
4. A client who has a severe headache from hypertensive crisis
Question 18
Type: MCSA
The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position
should the nurse face?
1. Toward the nearest corner of the head of the bed
2. Toward the side of the bed
3. Toward the far corner of the foot of the bed
4. Directly toward the client
Question 19
Type: MCSA
What is the priority action of the nurse prior to transferring a client from bed to wheelchair?
1. Place the bed in its lowest position.
2. Place the wheelchair parallel to the bed.
3. Lock the brakes on the bed.
4. Place a transfer belt on the client.
Question 20
Type: MCSA
The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed
is parallel to the stretcher and
1. slightly higher.
2. slightly lower.
3. at the same height.
4. at least 2 inches lower.
Question 21
Type: MCSA
The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting
up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member
should ambulate this client?
1. The UAP
2. A licensed practical (vocational) nurse
3. A registered nurse
4. It makes no difference
Question 22
Type: MCSA
The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains
of light-headedness and begins to faint. What is the nurse’s most important action?
1. Ensure the client’s modesty as she falls.
2. Be certain the client does not hit the head on anything.
3. Call for immediate assistance.
4. Check the vital signs and for excessive vaginal bleeding.
Question 23
Type: MCSA
The nurse is providing range-of-motion exercising to the client’s elbow when the client complains of pain. What
action should the nurse take?
1. Stop immediately and report the pain to the client’s physician.
2. Discontinue the treatment and document the results in the medical record.
3. Reduce the movement of the joint just until the point of slight resistance.
4. Continue to exercise the joint as before to loosen the stiffness.
Question 24
Type: MCMA
The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to
cause postural hypotension?
Standard Text: Select all that apply.
1. Hot baths
2. Heavy meals
3. Use of a rocking chair
4. Moving in bed
5. Bending down to the floor
Question 25
Type: MCMA
The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching?
Standard Text: Select all that apply.
1. Hold the cane on the weaker side of the body.
2. Move the cane forward while the body weight is between both legs.
3. The length of the cane should permit the elbow to be fully extended.
4. Move the weaker leg forward while the weight is between the cane and the stronger leg.
5. Move the stronger leg forward while the weight is between the cane and the weaker leg.