RPN Safety and Mobility Needs 3 — Questions and Answers
Question 1: A patient returning from surgery is alert but reports dizziness when sitting upright. The nurse's first action should be to:
- Lower the head of the bed and notify the surgeon
- Have the patient dangle at the bedside before standing
- Administer prescribed antiemetics before attempting ambulation
- Check blood pressure in supine and then sitting positions (Correct answer)
Correct answer: Check blood pressure in supine and then sitting positions
Orthostatic hypotension is a common post-operative finding; measuring blood pressure in supine and sitting positions confirms the cause before further action.
Question 2: When using a mechanical (Hoyer) lift to transfer a patient, the nurse must ensure:
- The sling is removed immediately once the patient is seated
- Two staff members are present during the transfer (Correct answer)
- The patient's feet touch the floor during the lift
- The lift is operated at maximum speed to reduce patient anxiety
Correct answer: Two staff members are present during the transfer
Policy and safety standards require a minimum of two staff members when operating a mechanical lift to prevent equipment failure injuries and ensure patient safety.
Question 3: A nurse notes a patient's peripheral IV site is cool, pale, and swollen. This assessment finding is consistent with:
- Phlebitis
- Infiltration (Correct answer)
- Infection
- Air embolism
Correct answer: Infiltration
Infiltration occurs when IV fluid leaks into surrounding tissue, causing coolness, pallor, and swelling at the site.
Question 4: Which patient is at HIGHEST risk for a fall?
- A 35-year-old post-operative patient who is NPO
- A 78-year-old taking furosemide and an antihypertensive who ambulates with a walker (Correct answer)
- A 60-year-old with diabetes mellitus who is on a regular diet
- A 50-year-old with a fractured wrist in a splint
Correct answer: A 78-year-old taking furosemide and an antihypertensive who ambulates with a walker
Advanced age, diuretic and antihypertensive use (increasing orthostatic hypotension risk), and use of an assistive device all significantly increase fall risk.
Question 5: The nurse is teaching a patient to use crutches with a swing-through gait. Which instruction is correct?
- Place crutches 4–6 inches in front and to the side, then swing both legs forward past the crutches
- Advance one crutch, step with the opposite foot, then advance the other crutch
- Keep the crutch pads firmly pressed into the axillae for support
- Bear weight through the wrists, not the axillae, when swinging (Correct answer)
Correct answer: Bear weight through the wrists, not the axillae, when swinging
Weight must be borne through the palms and wrists; axillary pressure can damage the brachial plexus nerve, causing 'crutch palsy.'
Question 6: A nurse is caring for a patient with a seizure disorder. Which safety measure is the highest priority?
- Keeping padded side rails up at all times (Correct answer)
- Placing a bite block at the bedside
- Maintaining a dim, quiet environment
- Inserting an oral airway between seizures
Correct answer: Keeping padded side rails up at all times
Padded, raised side rails protect the patient from injury during a seizure; bite blocks and oral airways are contraindicated and should never be forced into the mouth.
Question 7: A patient wearing a vest restraint needs to be repositioned. The nurse should:
- Remove the restraint, reposition the patient, then reapply (Correct answer)
- Reposition the patient with the restraint in place
- Loosen the restraint straps by 2 inches before repositioning
- Obtain a second nurse to hold the restraint during repositioning
Correct answer: Remove the restraint, reposition the patient, then reapply
The restraint must be removed to allow full range of motion and skin assessment during repositioning, then reapplied correctly after repositioning.
RPN Safety and Mobility Needs 3
A patient returning from surgery is alert but reports dizziness when sitting upright.
The nurse's first action should be to: