The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
Tilt the pelvis forwards and backwards.
Turn the head to the right and left.
Bend the arm by flexing the ulnar to the humerus.
Extend the arm at the side and rotate in circles.
The Correct Answer is C
Choice A rationale
Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.
Choice B rationale
Turning the head to the right and left exercises the neck joints, not the hinge joints.
Choice C rationale
Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.
Choice D rationale
Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.
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Correct Answer is D
Explanation
Choice A rationale
Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.
Choice B rationale
Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.
Choice C rationale
Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.
Choice D rationale
Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.
Correct Answer is A
Explanation
Choice A rationale
Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.
Choice B rationale
Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.
Choice C rationale
Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.
Choice D rationale
Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.