NCLEX-PN Test #16 1

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?

Accepted Answer

Hold the cane on the right (strong) side

Answer

Hold the cane on the left (weak) side

Answer

Switch the cane to whichever side feels more comfortable

Answer

Use the cane only when going up stairs

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?

Accepted Answer

Lock the wheelchair wheels

Answer

Remove the patient's footrests

Answer

Ensure the nurse's back is straight with feet shoulder-width apart

Answer

Raise the bed to its highest position

Question 3

A nurse is caring for a patient on bed rest. Which intervention is most important to prevent deep vein thrombosis (DVT)?

Accepted Answer

Encourage the patient to flex and extend the ankles every 1–2 hours

Answer

Keep the patient's legs crossed at the ankles while in bed

Answer

Position the patient in a prone position for most of the day

Answer

Apply ice packs to the lower extremities every 4 hours

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?

Accepted Answer

Ensure call light is within reach and bed is in lowest position

Answer

Apply a vest restraint to keep the patient in bed

Answer

Keep all four side rails raised at all times

Answer

Limit fluid intake to reduce nighttime urination

Question 5

A nurse is preparing to perform range-of-motion (ROM) exercises for a patient with contractures. Which approach is correct?

Accepted Answer

Move each joint slowly and smoothly to the point of resistance, not beyond

Answer

Move each joint rapidly through its full range to stretch the contracture

Answer

Perform ROM only on unaffected joints

Answer

Apply forceful pressure past the point of resistance to break up adhesions

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?

Accepted Answer

Ensure a raised toilet seat is in place to prevent hip flexion beyond 90 degrees

Answer

Allow the patient to squat on a standard-height toilet

Answer

Assist the patient to cross the operative leg over the other for support

Answer

Position the patient with the operative leg internally rotated