A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
Each movement is performed until the patient reports pain.
Each movement is moved just to the point of resistance by the nurse.
Each movement is repeated 5 times by the patient.
Each movement is completed quickly and smoothly by the nurse.
The Correct Answer is B
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.
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Correct Answer is A
Explanation
A. After a nurse is exposed to blood from a cut by a used scalpel, it is crucial to test the patient for bloodborne pathogens (e.g., HIV, hepatitis B, hepatitis C) and to offer post-exposure prophylaxis or treatment to the nurse if indicated.
B. While removing gloves and disposing of them properly is part of standard infection control practices, it is not the primary process required after an exposure incident.
C. Although the nurse should report the incident, providing a medical evaluation should follow the protocols established by the facility, not just the manager's assessment.
D. Properly disposing of the scalpel in a sharps container is necessary for safety but does not directly address the required process for managing exposure to blood.
Correct Answer is C
Explanation
A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.
B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.
C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.
D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.