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NCLEX RN – Activity and Mobility

NCLEX RN – Activity and Mobility

Complete guide to mobility assessment, complications of immobility, crutch/cane/walker use, and gait types – essential for NCLEX success.

A. Assessment of Mobility

  • Mobility status must be evaluated considering disease effects.
  • Begin with client lying in bed → sitting → transfer to chair → ambulation with/without devices.
  • Assistive devices promote independence and safe exercise.

B. Complications of Immobility

1. Metabolic

  • ↓ Endocrine function, metabolism, GI function.
  • ↓ Metabolic rate → fluid/electrolyte imbalance, GI issues.
  • ↓ Protein → negative nitrogen balance, ↓ muscle mass, weakness.
  • ↑ Calcium resorption → renal issues, fractures.
  • Constipation, impaction, pseudo-diarrhea, bowel obstruction.

2. Respiratory

  • Atelectasis (alveolar collapse), hypostatic pneumonia (pooled secretions).
  • Ineffective cough → retained secretions → pneumonia.

3. Cardiovascular

  • Orthostatic hypotension, ↑ cardiac workload, thrombus formation.
  • Symptoms: dizziness, nausea, pallor, tachycardia, syncope.
  • Thrombus = platelets/fibrin accumulation occluding vessels.

4. Musculoskeletal

  • ↓ Lean body mass, ↑ fall risk.
  • Disuse osteoporosis.
  • Joint contractures – e.g. foot-drop.

5. Urinary

  • Urinary stasis (↓ gravity effect when flat).
  • ↑ UTI, renal calculi risk due to stasis/dehydration.

6. Integumentary

  • Risk for pressure injuries at bony prominences.
  • ↓ Cellular metabolism/oxygenation under pressure.

7. Psychosocial

  • Cognitive, sensory, emotional disruption.
  • Depression, withdrawal due to routine disruption.

C. Crutch Walking

  • Ensure correct fit: 2–3 finger widths between axilla and pad.
  • Elbows flexed at 20–30°.
  • Do not rest axilla on bars – risk to brachial plexus.
  • Look ahead while ambulating, place crutches 6–10 inches forward.
  • Stop if numbness/tingling in arms.
  • Stand on affected side during ambulation.

Types of Gait

  • Two-point gait: Crutch + opposite foot → for partial weight-bearing on both legs.
  • Three-point gait: Both crutches + affected leg → then unaffected leg.
  • Four-point gait: Right crutch → left foot → left crutch → right foot.
  • Swing-through gait: Crutches forward → swing both legs past crutches (e.g., paraplegia).
NCLEX RN – Activity and Mobility

🔑 Bilingual Key Terms

Mobility Assessment
EN: Evaluating ability to move from bed to chair and walk. ES: Evaluación de la capacidad para pasar de la cama a la silla y caminar.
Assistive Devices
EN: Items like canes, walkers, or crutches to help movement. ES: Elementos como bastones, andadores o muletas para facilitar el movimiento.
Atelectasis
EN: Collapse of alveoli due to immobility. ES: Colapso de los alvéolos por inmovilidad.
Hypostatic Pneumonia
EN: Lung infection caused by pooled secretions. ES: Infección pulmonar por acumulación de secreciones.
Orthostatic Hypotension
EN: Drop in blood pressure when standing. ES: Caída de la presión al ponerse de pie.
Disuse Osteoporosis
EN: Bone loss due to lack of use or weight bearing. ES: Pérdida ósea por falta de uso o carga.
Foot-Drop
EN: Permanent downward position of the foot from immobility. ES: Posición caída del pie por inmovilidad prolongada.
Urinary Stasis
EN: Urine retention due to lying flat. ES: Retención de orina por estar acostado.
Pressure Injuries
EN: Skin breakdown from pressure, often on bony areas. ES: Deterioro de la piel por presión, frecuentemente en prominencias óseas.
Muscle Strength Scale
EN: 0 to 5 scale for evaluating muscle power. ES: Escala de 0 a 5 para evaluar la fuerza muscular.
Two-Point Gait
EN: Crutch and opposite foot move together. ES: Muleta y pie opuesto se mueven juntos.
Three-Point Gait
EN: Both crutches and affected leg move, then unaffected leg. ES: Ambas muletas y pierna afectada se mueven, luego la pierna sana.
Four-Point Gait
EN: Right crutch, left foot, left crutch, right foot. ES: Muleta derecha, pie izquierdo, muleta izquierda, pie derecho.
Swing-Through Gait
EN: Crutches forward, both legs swing past. ES: Muletas al frente, ambas piernas se balancean hacia adelante.
Cane Use
EN: Held on strong side, moves with weak leg. ES: Se sostiene del lado fuerte, avanza con la pierna débil.
Walker Use
EN: Walker → affected leg → strong leg sequence. ES: Secuencia: andador → pierna afectada → pierna fuerte.

🧠 NCLEX-Style Questions – Bilingual Format

Mobility Assessment
EN: Which sequence should the nurse use to assess mobility safely? ES: ¿Qué secuencia debe usar la enfermera para evaluar la movilidad de forma segura? Key Concept / Concepto Clave: Start with lying down → sitting → standing → walking.
Iniciar con el paciente acostado → sentado → de pie → caminando.
Complications: Respiratory
EN: What is a common respiratory complication of immobility? ES: ¿Cuál es una complicación respiratoria común de la inmovilidad? Key Concept / Concepto Clave: Atelectasis and hypostatic pneumonia.
Atelectasia y neumonía hipostática.
Crutch Walking
EN: What is the correct crutch placement to prevent nerve injury? ES: ¿Cuál es la colocación correcta de muletas para evitar lesión nerviosa? Key Concept / Concepto Clave: 2–3 finger-widths below axilla; don’t rest on pads.
2–3 dedos bajo la axila; no apoyar axilas en las muletas.
Gait Types
EN: Which gait is best for a client with partial weight-bearing on both legs? ES: ¿Qué tipo de marcha es mejor para un paciente con apoyo parcial en ambas piernas? Key Concept / Concepto Clave: Two-point gait.
Marcha de dos puntos.
Walker Use
EN: What is the correct sequence for using a walker? ES: ¿Cuál es la secuencia correcta para usar un andador? Key Concept / Concepto Clave: Walker → affected leg → unaffected leg.
Andador → pierna afectada → pierna sana.
Fall Risk
EN: What factors increase a client’s risk of falling? ES: ¿Qué factores aumentan el riesgo de caídas en un paciente? Key Concept / Concepto Clave: Muscle weakness, impaired vision, medications, unfamiliar environment.
Debilidad muscular, visión alterada, medicamentos, entorno desconocido.
Muscle Strength
EN: What does a score of 3 on the muscle strength scale indicate? ES: ¿Qué indica un puntaje de 3 en la escala de fuerza muscular? Key Concept / Concepto Clave: Movement against gravity but not resistance.
Movimiento contra la gravedad pero sin resistencia.
Safety Priority
EN: What should the nurse check on all assistive devices before use? ES: ¿Qué debe verificar la enfermera en todos los dispositivos antes de usarlos? Key Concept / Concepto Clave: Condition of rubber tips and proper fit.
Condición de las puntas de goma y ajuste adecuado.
NCLEX RN – Hygiene

NCLEX RN – Hygiene

Core Concepts

  • Hygiene includes bathing, oral care, nail care, foot care, perineal care, and grooming.
  • Nurses assess clients’ hygiene needs based on physical, cognitive, cultural, and environmental factors.
  • Hand hygiene is critical for infection control in all health settings.
  • Client education promotes independence and safety in performing hygiene tasks.

Self-Care Ability

  • Assess strength, flexibility, balance, vision, and ability to detect stimuli.
  • Monitor for activity intolerance (fatigue, changes in vital signs).

Bathing

  • Types: complete bed bath, partial bath, tub/shower, CHG wipes.
  • CHG reduces bacterial transmission better than soap and water.
  • Water temp: not above 110°F (43°C); ensure privacy and safety.
  • Assess for allergies to soaps and skin products.

Skin Care and Assessment

  • Evaluate color, turgor, temperature, moisture, lesions, and device-related pressure.
  • Risk factors: immobility, obesity, vascular insufficiency, incontinence, poor nutrition.

Perineal Care

  • Daily and as needed; crucial for clients with catheters or incontinence.
  • Assess for redness, odor, pain, or breakdown.

Foot and Nail Care

  • Inspect between toes and soles for cracks, infection, or deformities.
  • Soak and trim unless contraindicated (e.g., diabetes, PVD).
  • Apply lotion (not between toes) and wear clean, seam-free socks.

Oral Hygiene

  • Brush twice daily with fluoride toothpaste; floss and rinse regularly.
  • Assess for oral lesions, dry mouth, and gum issues.
  • Special needs: unconscious clients, diabetes, chemotherapy, radiation.
  • Denture care: remove at night, clean and store in labeled container.

Hair Care and Shaving

  • Brush, wash, and condition hair regularly; check scalp for lice or lesions.
  • Use electric razors for clients on anticoagulants.

Eyes, Ears, Nose Care

  • Clean eyes inner to outer canthus using separate cloth areas per eye.
  • Avoid Q-tips; assist with hearing aids, glasses, and lenses.
  • Assess function and comfort, especially under oxygen or feeding tubes.

Patient Education and Adaptations

  • Use assistive tools (grab bars, long-handled sponges) for ADLs.
  • Teach proper hygiene techniques to maintain independence and prevent infections.

Post-Mortem Care

  • Remove equipment, clean body, close eyes/jaw, apply shroud and ID tag.
  • Use standard precautions throughout the process.
✅ Hygiene care involves clinical skills, cultural sensitivity, patient teaching, and infection control awareness – all core expectations on the NCLEX-RN.
NCLEX RN – Hygiene

🧼 Key Terms – Hygiene (Bilingual)

CHG (Chlorhexidine)
A germ-killing solution used to clean skin and reduce infection.
Solución antiséptica que se usa para limpiar la piel y prevenir infecciones.
Perineal Care
Cleaning the private (genital and anal) areas.
Limpieza de las áreas íntimas (genitales y anales).
Complete Bed Bath
Nurse washes the full body of a bedbound patient.
El personal de enfermería baña completamente a un paciente en cama.
Partial Bed Bath
Patient helps with some parts of the bath.
El paciente colabora en parte del baño y el personal ayuda con el resto.
Maceration
Soft, damaged skin from staying wet too long.
Piel blanda y dañada por estar mojada por mucho tiempo.
Activity Intolerance
Person becomes too tired or weak to complete tasks like bathing or walking.
El paciente se cansa o debilita al realizar actividades como bañarse o caminar.
Oral Hygiene
Cleaning teeth, gums, and mouth to prevent infection.
Limpieza de dientes, encías y boca para evitar infecciones.
Denture Care
Cleaning and storing false teeth (dentures) properly.
Cuidado adecuado de las dentaduras postizas.
Pediculosis Capitis
Medical name for head lice.
Nombre médico para la infestación de piojos en la cabeza.
Callus/Corn
Thick, hard skin from pressure, common on feet.
Engrosamiento duro de la piel por presión, común en los pies.
Paronychia
Infection around the nails, often red and swollen.
Infección alrededor de las uñas, con enrojecimiento e hinchazón.
CHG Bath
A bath using chlorhexidine wipes instead of soap to kill germs.
Baño con toallas de clorhexidina en lugar de jabón, para eliminar bacterias.
Shaving Precautions
Use electric razors for clients on blood thinners.
Usar rasuradoras eléctricas si el paciente toma anticoagulantes.
Skin Breakdown
Damaged skin from pressure or moisture, may lead to sores.
Deterioro de la piel por presión o humedad, puede causar úlceras.
Assistive Devices
Tools that help clients with hygiene (e.g., grab bars, shower chairs).
Herramientas que ayudan con la higiene (como barras de apoyo o sillas de baño).

🧼 Bilingual NCLEX Hygiene Questions

Bathing
What ensures patient safety during a complete bed bath?
¿Qué asegura la seguridad del paciente durante un baño completo en cama?
✅ Ensure water temp ≤ 110°F, provide privacy, raise side rails, assess tolerance.
✅ Asegura temperatura ≤ 43 °C, brinda privacidad, sube barandas y evalúa tolerancia.
Skin Assessment
A nurse notes redness under skin folds. What is the priority action?
Una enfermera nota enrojecimiento bajo pliegues cutáneos. ¿Qué debe hacer primero?
✅ Check for moisture, infection risk, and pressure injury.
✅ Verificar humedad, riesgo de infección y úlceras por presión.
Perineal Care
Who is at highest risk for perineal skin breakdown?
¿Quién tiene mayor riesgo de deterioro de la piel perineal?
✅ Incontinence, obesity, surgery, catheters = high risk.
✅ Incontinencia, obesidad, cirugía y sondas aumentan el riesgo.
Foot/Nail Care
What action requires intervention in diabetic foot care?
¿Qué acción requiere intervención en el cuidado del pie diabético?
✅ Don’t soak or trim nails. Refer to podiatry.
✅ No remojar ni cortar uñas. Consultar podólogo.
Oral Hygiene
How should oral care be provided to an unconscious client?
¿Cómo debe darse la higiene oral a un paciente inconsciente?
✅ Turn head to side, use suction, prevent aspiration.
✅ Girar cabeza, usar succión, prevenir aspiración.
Hair/Shaving
What is the safest method to shave a patient on blood thinners?
¿Cuál es el método más seguro para afeitar a un paciente con anticoagulantes?
✅ Use electric razor to avoid bleeding.
✅ Usar rasuradora eléctrica para evitar sangrado.
Eye Care
How should the nurse clean a patient’s eyes?
¿Cómo debe la enfermera limpiar los ojos del paciente?
✅ Wipe inner to outer, use a clean part of cloth per eye.
✅ Limpiar de adentro hacia afuera con parte limpia del paño.
ADL Adaptations
Which device helps patients with limited mobility maintain hygiene?
¿Qué dispositivo ayuda con la higiene en pacientes con movilidad limitada?
✅ Use assistive devices like grab bars, long sponges.
✅ Usar barras, esponjas largas u otros dispositivos de ayuda.
Post-Mortem Care
What is the first step in post-mortem care?
¿Cuál es el primer paso en el cuidado post-mortem?
✅ Remove tubes, clean body, align limbs, use ID tags.
✅ Retirar tubos, asear cuerpo, alinear extremidades, colocar etiquetas.

Now that you have explored the Skills  lesson, it’s time to test your understanding. Practice with questions specifically designed to reinforce your knowledge and prepare you for real-world scenarios. Remember, practice makes perfect!