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

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?

Accepted Answer

Lock the wheelchair wheels

Answer

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)?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #16 1