RPN Safety and Mobility Needs 5 — Questions and Answers
Question 1: A nurse is assessing a patient's Morse Fall Scale. Which factor contributes the MOST points to this score?
- Age over 65
- History of falling in the past 3 months (Correct answer)
- Secondary diagnosis
- Use of ambulatory aid
Correct answer: History of falling in the past 3 months
A history of falling within the past 3 months carries the highest weighted score (25 points) on the Morse Fall Scale, making it the strongest predictor of future falls.
Question 2: During ambulation, a patient begins to faint. The nurse's correct response is to:
- Call for help immediately and leave the patient to get assistance
- Lower the patient to the floor in a controlled manner by sliding them down the nurse's leg (Correct answer)
- Support the patient upright and walk them back to bed as quickly as possible
- Sit the patient directly on the floor to prevent falling
Correct answer: Lower the patient to the floor in a controlled manner by sliding them down the nurse's leg
A controlled descent by sliding the patient down the nurse's leg protects both the patient and nurse from injury when the patient cannot support their own weight.
Question 3: A patient with a right total hip replacement asks when they should use the abductor pillow in bed. The nurse's best response is:
- Only at night while sleeping
- Whenever lying in bed to keep the hip in proper alignment (Correct answer)
- Only during the first 24 hours after surgery
- Only when turning to the operative side
Correct answer: Whenever lying in bed to keep the hip in proper alignment
The abductor pillow maintains hip abduction and prevents adduction past midline, which is required continuously while in bed to prevent hip dislocation.
Question 4: A nurse notes that a patient has a Braden Scale score of 14. This score indicates the patient is at which level of pressure injury risk?
- No risk
- Mild risk (Correct answer)
- Moderate risk
- High risk
Correct answer: Mild risk
A Braden Scale score of 15–18 indicates mild risk; scores of 13–14 indicate moderate risk, 10–12 indicate high risk, and ≤9 indicate very high risk.
Question 5: A patient on contact precautions for MRSA requires assistance walking to the bathroom. The nurse should:
- Have the patient use a bedpan instead to avoid leaving the room
- Don gloves and gown, assist the patient, then remove PPE and perform hand hygiene (Correct answer)
- Wear only gloves since the patient is ambulatory
- Ask the patient to perform hand hygiene and walk unassisted to limit staff contact
Correct answer: Don gloves and gown, assist the patient, then remove PPE and perform hand hygiene
Contact precautions require both gloves and a gown during any patient contact; proper PPE donning and doffing with hand hygiene prevents transmission.
Question 6: Which patient statement indicates a need for further teaching about safe use of a quad cane?
- 'I will place the cane on my stronger side when walking.'
- 'I will make sure all four tips touch the floor before I put weight on the cane.'
- 'I can use the cane handle to push myself up from a chair.' (Correct answer)
- 'I will advance the cane before stepping forward with my weaker leg.'
Correct answer: 'I can use the cane handle to push myself up from a chair.'
Using the cane handle to push up from a chair is unsafe because it can tip the cane and cause a fall; the patient should push up from the chair armrests.
Question 7: A nurse is caring for a patient with lower extremity weakness who uses a gait belt. Where should the nurse position themselves during ambulation?
- Directly in front of the patient to catch them if they fall forward
- Behind and to the stronger side of the patient
- Behind and to the weaker side of the patient, grasping the belt (Correct answer)
- To the side of the patient, holding their arm
Correct answer: Behind and to the weaker side of the patient, grasping the belt
Standing behind and to the weaker side with a firm grip on the gait belt allows the nurse to prevent falls toward the weaker side, which is most likely.
RPN Safety and Mobility Needs 5
A nurse is assessing a patient's Morse Fall Scale.
Which factor contributes the MOST points to this score?