A client with a sprained left ankle uses axillary crutches and must go down a flight of stairs at home. The nurse teaches the client to move first:

The crutches and the injured leg down to the lower step

The uninjured leg and one crutch at the same time

The uninjured leg down to the lower step

Both crutches down, then both legs together

An 84-year-old man was admitted 2 hours ago with pneumonia. He answers questions with unrelated replies and looks at the nurse blankly. His daughter says he is "sharp as a tack" at home but wears hearing aids in both ears, which were left at home. Temperature 99.1°F (37.3°C), SpO2 95% on room air, blood glucose 112 mg/dL. Which action should the nurse take first?

Get his hearing aids or an amplifier, then reassess him

Report new-onset delirium to the health care provider at once

Apply a bed alarm and place him on fall precautions

Ask the provider for a sedative to calm him tonight

A client's forearm cast was removed today. The skin beneath is dry, scaly and pale. What should the nurse teach the client about skin care?

Wash gently with mild soap and apply a moisturizing lotion

Soak the arm in hot water to loosen the scales

Scrub the flaky skin off firmly with a washcloth

Leave the skin unwashed until the flaking stops

A client with a weak right leg after a knee injury is learning to walk with a single-point cane. The nurse should teach the client to hold the cane in the:

Left hand and advance it with the right leg

Left hand and advance it with the left leg

Right hand and advance it before both legs

Right hand and advance it with the right leg

A client intubated for 5 days has a small ulcer on the lower lip where the endotracheal tube rests. How should the nurse document this wound?

As a mucosal membrane pressure injury, which is not staged

As a stage 3 pressure injury, because it involves tissue loss

As an unstageable pressure injury, because it is on the lip

As a stage 2 pressure injury, because it is shallow

Mobility, positioning, skin integrity and assistive devices

48 NCLEX-RN practice questions on Mobility, positioning, skin integrity and assistive devices, part of Basic Care and Comfort. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A client with a sprained left ankle uses axillary crutches and must go down a flight of stairs at home. The nurse teaches the client to move first:
1. AThe crutches and the injured leg down to the lower step
2. BThe uninjured leg and one crutch at the same time
3. CThe uninjured leg down to the lower step
4. DBoth crutches down, then both legs together
Show answerHide answer
Answer: A · The crutches and the injured leg down to the lower step
Going down stairs, the crutches and the affected leg go down first, and the strong leg follows, so the strong leg lowers the body under control. Going up it is the reverse: the strong leg steps up first, then the crutches and affected leg. The phrase "up with the good, down with the bad" helps clients remember. This item tests generating solutions.
- B: Splitting the crutches unbalances the client on a stair.
- C: Leading with the strong leg going down leaves the weak leg to lower the body.
- D: Moving both legs together is a swing gait, unsafe on stairs.
Question 2 · Hard
An 84-year-old man was admitted 2 hours ago with pneumonia. He answers questions with unrelated replies and looks at the nurse blankly. His daughter says he is "sharp as a tack" at home but wears hearing aids in both ears, which were left at home. Temperature 99.1°F (37.3°C), SpO2 95% on room air, blood glucose 112 mg/dL. Which action should the nurse take first?
1. AReport new-onset delirium to the health care provider at once
2. BGet his hearing aids or an amplifier, then reassess him
3. CApply a bed alarm and place him on fall precautions
4. DAsk the provider for a sedative to calm him tonight
Show answerHide answer
Answer: B · Get his hearing aids or an amplifier, then reassess him
His vital signs, oxygen saturation and glucose are reassuring, and his family says he is normally alert. Inappropriate answers in a client who cannot hear may be a hearing problem, not confusion. Restoring his hearing (his own aids, or a pocket amplifier) and then reassessing tells the nurse whether a true change in mental state exists. Labelling him as delirious or sedating him without that step could lead to wrong care. This item tests analysing cues.
- A: Calling delirium before correcting his hearing may mislabel a sensory problem.
- C: Fall precautions may be useful but do not address the likely cause.
- D: A sedative would worsen confusion and is not indicated.
Question 3 · Medium
A client's forearm cast was removed today. The skin beneath is dry, scaly and pale. What should the nurse teach the client about skin care?
1. ASoak the arm in hot water to loosen the scales
2. BWash gently with mild soap and apply a moisturizing lotion
3. CScrub the flaky skin off firmly with a washcloth
4. DLeave the skin unwashed until the flaking stops
Show answerHide answer
Answer: B · Wash gently with mild soap and apply a moisturizing lotion
After weeks under a cast, dead skin and sebum build up and the skin is dry and fragile. Gentle washing with warm water and mild soap, patting dry and applying lotion let the scales come away over several days. Scrubbing or hot soaks injure the new skin. The client is also told the limb may look thin and feel stiff and that exercise will restore it. This item tests generating solutions.
- A: Hot water can burn skin whose sensation may still be reduced.
- C: Firm scrubbing tears the fragile new skin underneath.
- D: Washing is needed; leaving the skin dirty adds to the debris.
Question 4 · Easy
A client with a weak right leg after a knee injury is learning to walk with a single-point cane. The nurse should teach the client to hold the cane in the:
1. ALeft hand and advance it with the right leg
2. BLeft hand and advance it with the left leg
3. CRight hand and advance it before both legs
4. DRight hand and advance it with the right leg
Show answerHide answer
Answer: A · Left hand and advance it with the right leg
The cane is held on the stronger side, opposite the affected leg. The cane and the weak leg move forward together, so the cane shares the load the weak leg would carry, and the strong leg then steps through. This mirrors the normal arm swing and gives a wider base of support. This item tests generating solutions.
- B: Moving the cane with the strong leg leaves the weak leg unsupported.
- C: The cane belongs on the strong side and moves with the weak leg, not ahead of both.
- D: Holding it on the weak side makes the client lean toward the injury and narrows the base.
Question 5 · Hard
A client intubated for 5 days has a small ulcer on the lower lip where the endotracheal tube rests. How should the nurse document this wound?
1. AAs a stage 3 pressure injury, because it involves tissue loss
2. BAs an unstageable pressure injury, because it is on the lip
3. CAs a mucosal membrane pressure injury, which is not staged
4. DAs a stage 2 pressure injury, because it is shallow
Show answerHide answer
Answer: C · As a mucosal membrane pressure injury, which is not staged
Pressure injuries on mucous membranes, such as the lips, mouth or nose from a tube or device, are called mucosal membrane pressure injuries. The tissue has no layers like skin, so the skin staging system cannot be used. A device-related injury on skin, by contrast, is staged with the usual system. The nurse also repositions the tube as per protocol to relieve the pressure. This item tests recognising cues.
- A: Stage 3 describes full-thickness skin loss, not mucosa.
- B: Unstageable means skin whose base is hidden by slough or eschar.
- D: Mucosa has no epidermis and dermis, so the stage 2 label does not apply.
Question 6 · Medium
A client with a new long arm cast says the skin under the cast itches badly. Which advice by the nurse is most appropriate?
1. ASprinkle talcum powder into the cast to dry the skin
2. BPour a little lotion inside the cast edge to soothe it
3. CSlide a knitting needle under the cast to reach the itch
4. DBlow cool air into the cast with a hair dryer
Answer and explanation in LearnFree account
Question 7 · Hard
Ten days after a forearm plaster cast was applied, a client reports a burning pain under the cast. The nurse notes a foul odor and a warm area on the outside of the cast over the painful spot. Fingers are pink, with brisk capillary refill. The nurse interprets these findings as most likely:
1. AAn infection or pressure ulcer under the cast
2. BExpected healing pain at the fracture site
3. CNormal drying of the plaster material
4. DAcute compartment syndrome in the forearm
Answer and explanation in LearnFree account
Question 8 · Medium
The nurse finds a reddened area over a client's coccyx after the client has been supine for 2 hours. What should the nurse do next to tell a stage 1 injury from reactive hyperemia?
1. AMeasure the area and photograph it for the chart
2. BApply a hydrocolloid dressing over the redness
3. CPress on the area and see whether it blanches
4. DMassage the area firmly to restore its circulation
Answer and explanation in LearnFree account
Question 9 · Hard
A client with fecal incontinence has red, shiny, weeping skin with diffuse, irregular edges spread across both buttocks and into the gluteal cleft. No area lies over a bony prominence, and there is no tissue loss beyond the top layer. Which plan is most appropriate?
1. AStage the area as a stage 2 pressure injury and apply foam
2. BCleanse gently after each episode and apply a skin barrier product
3. CLeave the area uncovered and dry it with a heat lamp
4. DApply a transparent film dressing over the gluteal cleft
Answer and explanation in LearnFree account
Question 10 · Easy
The correct way to care for a client's behind-the-ear hearing aid at bedtime is to:
1. ARinse it under warm water before storing it
2. BLeave it switched on in the client's ear overnight
3. CSoak the earmold in alcohol until morning
4. DTurn it off, open the battery door, store it dry
Answer and explanation in LearnFree account
Question 11 · Hard
A client with weakness in both legs can bear partial weight on each leg and is learning to use crutches. The physical therapist wants the most stable crutch gait. Which gait will the nurse reinforce?
1. AFour-point gait
2. BThree-point gait
3. CTwo-point gait
4. DSwing-through gait
Answer and explanation in LearnFree account
Question 12 · Medium
During passive range-of-motion exercises for a client who cannot move independently, the nurse should move each joint:
1. AQuickly through its range so the muscles do not tire
2. BTo the point of resistance, supporting it above and below
3. CPast the point of pain to gain more joint flexibility
4. DOnly once a day, to avoid stiffness from overuse
Answer and explanation in LearnFree account
Question 13 · Hard
A client's stage 3 sacral pressure injury has been treated for 3 weeks. Today the wound is smaller and its base is filled with beefy red, granular tissue. How should the nurse document the wound?
1. AAs a stage 2 pressure injury
2. BAs an unstageable pressure injury
3. CAs a stage 1 pressure injury
4. DAs a healing stage 3 pressure injury
Answer and explanation in LearnFree account
Question 14 · Medium
A client with peripheral arterial disease has a dry, black, firmly attached eschar on the heel with no redness, swelling or drainage around it. Which plan is most appropriate?
1. AKeep the eschar intact and float the heel off the bed
2. BSoften the eschar with a moist hydrogel dressing
3. CAsk for a sharp debridement of the eschar today
4. DSoak the foot in warm water twice a day
Answer and explanation in LearnFree account
Question 15 · Medium
A client with darkly pigmented skin has been lying on the left side for several hours. Which assessment finding over the left hip is most consistent with a stage 1 pressure injury?
1. AA light pink area that fades within a few minutes of turning the client
2. BAn area warmer, firmer and more purple than the nearby skin
3. CA dry, flaky patch of skin with fine scaling
4. DA shallow open area with a pink, moist wound bed
Answer and explanation in LearnFree account
Question 16 · Hard
At 0700 shift change on an orthopedic unit, the handoff notes describe four clients. Whose bedside does the nurse go to first?
1. AA client 4 hours after a leg cast with numb toes and capillary refill of 4 s
2. BA client being discharged today who needs teaching on crutch walking
3. CA client with a stage 2 sacral pressure injury whose dressing change is due right now
4. DA client with a 3-day-old arm cast who says the skin under it itches
Answer and explanation in LearnFree account
Question 17 · Hard
A client in skeletal traction for a femur fracture has slid down the bed, and the traction footplate is now touching the end of the bed frame. The client reports increasing thigh pain. Pedal pulses are present, and the skin is warm. What is the nurse's first action?
1. ACall the health care provider to readjust the traction setup
2. BGive the prescribed as-needed opioid and then reassess the pain
3. CRemove the weights so that the client can be repositioned more easily
4. DHelp the client up in bed, keeping the weights hanging freely
Answer and explanation in LearnFree account
Question 18 · Medium
During pin care on day 4 of skeletal traction for a tibial fracture, the nurse inspects each pin. Which observation suggests a complication?
1. AMild tenderness when the pin site is cleaned
2. BSlight crusting around the pin entry point
3. CThick yellow drainage with spreading redness around the pin
4. DA small amount of clear fluid on the dressing on day 1
Answer and explanation in LearnFree account
Question 19 · Easy
A client confined to bed has an intact blister filled with clear serous fluid over the sacrum, caused by pressure. The nurse documents this as a:
1. AStage 2 pressure injury
2. BDeep tissue pressure injury
3. CStage 3 pressure injury
4. DStage 1 pressure injury
Answer and explanation in LearnFree account
Question 20 · Medium
An 82-year-old client with moderate hearing loss is being admitted. Which communication approach should the nurse use?
1. ASpeak loudly from behind so the client is not startled
2. BFace the client and speak clearly in a lower-pitched voice
3. CTalk quickly so the conversation does not tire the client
4. DDirect all of the admission questions to the family members present
Answer and explanation in LearnFree account
Question 21 · Medium
A client with left-sided paralysis lies supine and the left leg keeps rolling outward. The nurse should place a:
1. ATrochanter roll along the outer left thigh
2. BHand roll in the client's left hand
3. CPillow under the left knee for long periods
4. DFootboard against the sole of the left foot
Answer and explanation in LearnFree account
Question 22 · Medium
A client on bed rest has a Braden score of 14 and intact skin. Which part of the skin-care plan may the RN assign to assistive personnel?
1. ADeciding whether an air mattress is needed
2. BTeaching the client how to shift weight in bed
3. CTurning the client every 2 hours as scheduled
4. DStaging a new reddened area found on the sacrum
Answer and explanation in LearnFree account
Question 23 · Easy
When fitting axillary crutches, the nurse checks that the client's elbows are flexed about 20 to 30 degrees while gripping the handpieces. What is the main reason for this check?
1. AIt keeps the crutch tips close against the feet
2. BIt lets the client lean the axillae onto the pads
3. CBody weight is carried on the hands, not the axillae
4. DIt allows the client to bear full weight on both legs
Answer and explanation in LearnFree account
Question 24 · Easy
On the Braden scale, which total score indicates the greatest risk of developing a pressure injury?
1. A20
2. B16
3. C9
4. D13
Answer and explanation in LearnFree account
Question 25 · Medium
The nurse teaches a client to use a standard pickup walker. Which client statement shows the teaching was understood?
1. A"I will bend over the walker so it carries most of my weight."
2. B"I will pull on the walker to help me stand up from the chair."
3. C"I will move the walker ahead, then step in with my weak leg first."
4. D"I will keep stepping forward until I reach the front bar of the walker."
Answer and explanation in LearnFree account

23 more Mobility, positioning, skin integrity and assistive devices questions

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Mobility, positioning, skin integrity and assistive devices

A client with a sprained left ankle uses axillary crutches and must go down a flight of stairs at home. The nurse teaches the client to move first:

A client's forearm cast was removed today. The skin beneath is dry, scaly and pale. What should the nurse teach the client about skin care?

A client with a weak right leg after a knee injury is learning to walk with a single-point cane. The nurse should teach the client to hold the cane in the:

A client intubated for 5 days has a small ulcer on the lower lip where the endotracheal tube rests. How should the nurse document this wound?

A client with a new long arm cast says the skin under the cast itches badly. Which advice by the nurse is most appropriate?

Ten days after a forearm plaster cast was applied, a client reports a burning pain under the cast. The nurse notes a foul odor and a warm area on the outside of the cast over the painful spot. Fingers are pink, with brisk capillary refill. The nurse interprets these findings as most likely:

The nurse finds a reddened area over a client's coccyx after the client has been supine for 2 hours. What should the nurse do next to tell a stage 1 injury from reactive hyperemia?

A client with fecal incontinence has red, shiny, weeping skin with diffuse, irregular edges spread across both buttocks and into the gluteal cleft. No area lies over a bony prominence, and there is no tissue loss beyond the top layer. Which plan is most appropriate?

The correct way to care for a client's behind-the-ear hearing aid at bedtime is to:

A client with weakness in both legs can bear partial weight on each leg and is learning to use crutches. The physical therapist wants the most stable crutch gait. Which gait will the nurse reinforce?

During passive range-of-motion exercises for a client who cannot move independently, the nurse should move each joint:

A client's stage 3 sacral pressure injury has been treated for 3 weeks. Today the wound is smaller and its base is filled with beefy red, granular tissue. How should the nurse document the wound?

A client with peripheral arterial disease has a dry, black, firmly attached eschar on the heel with no redness, swelling or drainage around it. Which plan is most appropriate?

A client with darkly pigmented skin has been lying on the left side for several hours. Which assessment finding over the left hip is most consistent with a stage 1 pressure injury?

At 0700 shift change on an orthopedic unit, the handoff notes describe four clients. Whose bedside does the nurse go to first?

A client in skeletal traction for a femur fracture has slid down the bed, and the traction footplate is now touching the end of the bed frame. The client reports increasing thigh pain. Pedal pulses are present, and the skin is warm. What is the nurse's first action?

During pin care on day 4 of skeletal traction for a tibial fracture, the nurse inspects each pin. Which observation suggests a complication?

A client confined to bed has an intact blister filled with clear serous fluid over the sacrum, caused by pressure. The nurse documents this as a:

An 82-year-old client with moderate hearing loss is being admitted. Which communication approach should the nurse use?

A client with left-sided paralysis lies supine and the left leg keeps rolling outward. The nurse should place a:

A client on bed rest has a Braden score of 14 and intact skin. Which part of the skin-care plan may the RN assign to assistive personnel?

When fitting axillary crutches, the nurse checks that the client's elbows are flexed about 20 to 30 degrees while gripping the handpieces. What is the main reason for this check?

On the Braden scale, which total score indicates the greatest risk of developing a pressure injury?

The nurse teaches a client to use a standard pickup walker. Which client statement shows the teaching was understood?