RPN Safety and Mobility Needs 4 — Questions and Answers
Question 1: A nurse applies sequential compression devices (SCDs) to a post-operative patient. The PRIMARY purpose of this intervention is to:
- Reduce post-operative edema in the lower extremities
- Prevent deep vein thrombosis by promoting venous return (Correct answer)
- Relieve pressure on bony prominences during bed rest
- Stabilize the knee joint after orthopedic surgery
Correct answer: Prevent deep vein thrombosis by promoting venous return
SCDs intermittently compress the legs to mimic the calf muscle pump, promoting venous return and preventing DVT in immobile post-operative patients.
Question 2: When performing passive range-of-motion (ROM) exercises on a patient's hip, the nurse should stop and reassess if:
- The patient reports mild stiffness at the beginning of movement
- The joint reaches its normal end range
- The patient reports pain during the exercise (Correct answer)
- The movement requires gentle sustained pressure
Correct answer: The patient reports pain during the exercise
Passive ROM should be performed within the pain-free range; pain indicates possible injury, inflammation, or exceeding the joint's safe limits.
Question 3: A confused elderly patient keeps trying to climb out of bed despite interventions. Before applying a physical restraint, the nurse should first:
- Obtain a physician's order and apply the least restrictive restraint available (Correct answer)
- Apply mitts to prevent IV dislodgement
- Document the behavior and place the patient on 1:1 observation
- Notify the family and ask them to stay with the patient overnight
Correct answer: Obtain a physician's order and apply the least restrictive restraint available
Restraints require a physician's order and must be the least restrictive option necessary; this is the mandatory first step before application.
Question 4: A nurse discovers a patient on the floor after a fall. After calling for help, the nurse's next priority action is to:
- Help the patient back to bed to prevent further injury
- Assess the patient for injury before moving them (Correct answer)
- Complete the incident report while waiting for help
- Check the patient's last set of vital signs in the chart
Correct answer: Assess the patient for injury before moving them
The patient must be assessed for injuries such as fractures or head trauma before any attempt to move them, to avoid worsening an existing injury.
Question 5: Which nursing action is MOST effective in preventing hospital-acquired pressure injuries in an immobile patient?
- Applying a barrier cream to all skin surfaces twice daily
- Repositioning the patient at least every 2 hours (Correct answer)
- Massaging bony prominences to improve circulation
- Using a standard foam mattress with an absorbent pad
Correct answer: Repositioning the patient at least every 2 hours
Regular repositioning every 2 hours relieves sustained pressure on vulnerable tissues and is the cornerstone of pressure injury prevention.
Question 6: A nurse is preparing to ambulate a patient for the first time after three days of bed rest. Which action should the nurse take FIRST?
- Apply non-skid footwear before getting the patient out of bed
- Have the patient sit upright at the bedside for several minutes before standing (Correct answer)
- Check the patient's last documented blood pressure and pulse
- Obtain a gait belt and place it around the patient's waist
Correct answer: Have the patient sit upright at the bedside for several minutes before standing
Dangling at the bedside allows the cardiovascular system to adjust before the patient stands, preventing orthostatic hypotension and falls.
Question 7: Which of the following is a contraindication for the use of a heating pad on a patient?
- Mild muscle soreness after physical therapy
- Decreased sensation in the extremity being treated (Correct answer)
- Patient preference for moist rather than dry heat
- The patient is over 65 years of age
Correct answer: Decreased sensation in the extremity being treated
Decreased or absent sensation prevents the patient from detecting excessive heat, creating high risk for thermal burns.
RPN Safety and Mobility Needs 4
A nurse applies sequential compression devices (SCDs) to a post-operative patient.
The PRIMARY purpose of this intervention is to: