Rasmussen University NUR 2243 Module 6 (pdf) | 2026/2027 | Prof
Nursing Skills I Q&A | Nursing
1. Which of the following best describes the primary purpose of assessing
vital signs in a clinical setting?
A) To establish a baseline for comparison and detect changes in a client's
condition
B) To determine the client's favorite food preferences
C) To evaluate the client's financial status for billing purposes
D) To assess the client's level of education
Correct Answer: To establish a baseline for comparison and detect changes in
a client's condition
Rationale: Vital signs provide objective data that establish a baseline for a
client's normal values. Monitoring and comparing subsequent measurements
helps detect early signs of clinical deterioration or improvement. The other
options are not purposes of vital sign assessment.
2. A nurse is preparing to take an apical pulse. At which anatomical location
should the stethoscope be placed?
A) The second intercostal space at the right sternal border
B) The fifth intercostal space at the left midclavicular line
C) The fourth intercostal space at the left sternal border
D) The second intercostal space at the left sternal border
Correct Answer: The fifth intercostal space at the left midclavicular line
Rationale: The point of maximal impulse (PMI) for the apical pulse is located
at the fifth intercostal space at the left midclavicular line. The other locations
correspond to areas for auscultating heart valves but are not the PMI.
,3. A client's radial pulse is irregular. Which action should the nurse take next?
A) Document the finding and continue the assessment
B) Auscultate the apical pulse for a full minute
C) Reassess the radial pulse in 30 minutes
D) Notify the healthcare provider immediately
Correct Answer: Auscultate the apical pulse for a full minute
Rationale: An irregular peripheral pulse should be verified by auscultating the
apical pulse for a full minute to obtain an accurate rate and detect any
dysrhythmias. Documentation and notification are important but secondary
to an accurate assessment.
4. A nurse is assessing a client's respiratory rate. Which technique is most
accurate?
A) Count respirations for 30 seconds and multiply by 2
B) Count respirations for a full 60 seconds without informing the client
C) Count respirations for 15 seconds and multiply by 4
D) Observe the client's chest movement while taking the pulse
Correct Answer: Count respirations for a full 60 seconds without informing
the client
Rationale: Counting respirations for a full minute provides the most accurate
rate, especially if the rhythm is irregular. Not informing the client prevents
voluntary changes in breathing pattern. Observing while taking the pulse is a
good technique but a full 60-second count is most accurate.
,5. A nurse is applying a wrist restraint to a client. Which action indicates
correct technique?
A) Securing the restraint to the side rail of the bed
B) Tying the restraint with a double knot
C) Using a quick-release knot to secure the restraint to the bed frame
D) Applying the restraint tightly to prevent movement
Correct Answer: Using a quick-release knot to secure the restraint to the bed
frame
Rationale: Restraints must be secured to the bed frame using a quick-release
knot to allow for rapid removal in an emergency. Securing to side rails can
cause injury when the rails are lowered. Restraints should allow for 1-2
fingers of space.
6. A client is in a vest restraint. How often must the nurse assess the client's
circulation, skin integrity, and comfort?
A) Every 15 minutes
B) Every 2 hours
C) Every 4 hours
D) Every 8 hours
Correct Answer: Every 2 hours
Rationale: Clients in restraints must be assessed at least every 2 hours for
circulation, skin integrity, and comfort. More frequent assessments may be
needed based on the client's condition and facility policy.
7. Which of the following is a serious complication of immobility that the
nurse should monitor for in a client on bed rest?
, A) Increased appetite
B) Hypocalcemia
C) Deep vein thrombosis (DVT)
D) Hyperthermia
Correct Answer: Deep vein thrombosis (DVT)
Rationale: Deep vein thrombosis (DVT) is a major complication of immobility
due to venous stasis. The nurse should implement DVT prophylaxis and
monitor for signs such as unilateral leg swelling, pain, and warmth.
8. A client who has been on bed rest for 3 days suddenly develops shortness
of breath and chest pain. Which complication should the nurse suspect?
A) Pulmonary embolism
B) Atelectasis
C) Constipation
D) Urinary retention
Correct Answer: Pulmonary embolism
Rationale: Sudden shortness of breath and chest pain in an immobile client
are classic signs of a pulmonary embolism (PE), which can occur when a DVT
dislodges and travels to the lungs. This is a medical emergency.
9. A nurse is preparing to perform a sterile dressing change. Which action
maintains the sterility of the field?
A) Placing sterile items within the 1-inch border of the field
B) Placing sterile items outside the 1-inch border of the field
C) Reaching over the sterile field to retrieve supplies
Nursing Skills I Q&A | Nursing
1. Which of the following best describes the primary purpose of assessing
vital signs in a clinical setting?
A) To establish a baseline for comparison and detect changes in a client's
condition
B) To determine the client's favorite food preferences
C) To evaluate the client's financial status for billing purposes
D) To assess the client's level of education
Correct Answer: To establish a baseline for comparison and detect changes in
a client's condition
Rationale: Vital signs provide objective data that establish a baseline for a
client's normal values. Monitoring and comparing subsequent measurements
helps detect early signs of clinical deterioration or improvement. The other
options are not purposes of vital sign assessment.
2. A nurse is preparing to take an apical pulse. At which anatomical location
should the stethoscope be placed?
A) The second intercostal space at the right sternal border
B) The fifth intercostal space at the left midclavicular line
C) The fourth intercostal space at the left sternal border
D) The second intercostal space at the left sternal border
Correct Answer: The fifth intercostal space at the left midclavicular line
Rationale: The point of maximal impulse (PMI) for the apical pulse is located
at the fifth intercostal space at the left midclavicular line. The other locations
correspond to areas for auscultating heart valves but are not the PMI.
,3. A client's radial pulse is irregular. Which action should the nurse take next?
A) Document the finding and continue the assessment
B) Auscultate the apical pulse for a full minute
C) Reassess the radial pulse in 30 minutes
D) Notify the healthcare provider immediately
Correct Answer: Auscultate the apical pulse for a full minute
Rationale: An irregular peripheral pulse should be verified by auscultating the
apical pulse for a full minute to obtain an accurate rate and detect any
dysrhythmias. Documentation and notification are important but secondary
to an accurate assessment.
4. A nurse is assessing a client's respiratory rate. Which technique is most
accurate?
A) Count respirations for 30 seconds and multiply by 2
B) Count respirations for a full 60 seconds without informing the client
C) Count respirations for 15 seconds and multiply by 4
D) Observe the client's chest movement while taking the pulse
Correct Answer: Count respirations for a full 60 seconds without informing
the client
Rationale: Counting respirations for a full minute provides the most accurate
rate, especially if the rhythm is irregular. Not informing the client prevents
voluntary changes in breathing pattern. Observing while taking the pulse is a
good technique but a full 60-second count is most accurate.
,5. A nurse is applying a wrist restraint to a client. Which action indicates
correct technique?
A) Securing the restraint to the side rail of the bed
B) Tying the restraint with a double knot
C) Using a quick-release knot to secure the restraint to the bed frame
D) Applying the restraint tightly to prevent movement
Correct Answer: Using a quick-release knot to secure the restraint to the bed
frame
Rationale: Restraints must be secured to the bed frame using a quick-release
knot to allow for rapid removal in an emergency. Securing to side rails can
cause injury when the rails are lowered. Restraints should allow for 1-2
fingers of space.
6. A client is in a vest restraint. How often must the nurse assess the client's
circulation, skin integrity, and comfort?
A) Every 15 minutes
B) Every 2 hours
C) Every 4 hours
D) Every 8 hours
Correct Answer: Every 2 hours
Rationale: Clients in restraints must be assessed at least every 2 hours for
circulation, skin integrity, and comfort. More frequent assessments may be
needed based on the client's condition and facility policy.
7. Which of the following is a serious complication of immobility that the
nurse should monitor for in a client on bed rest?
, A) Increased appetite
B) Hypocalcemia
C) Deep vein thrombosis (DVT)
D) Hyperthermia
Correct Answer: Deep vein thrombosis (DVT)
Rationale: Deep vein thrombosis (DVT) is a major complication of immobility
due to venous stasis. The nurse should implement DVT prophylaxis and
monitor for signs such as unilateral leg swelling, pain, and warmth.
8. A client who has been on bed rest for 3 days suddenly develops shortness
of breath and chest pain. Which complication should the nurse suspect?
A) Pulmonary embolism
B) Atelectasis
C) Constipation
D) Urinary retention
Correct Answer: Pulmonary embolism
Rationale: Sudden shortness of breath and chest pain in an immobile client
are classic signs of a pulmonary embolism (PE), which can occur when a DVT
dislodges and travels to the lungs. This is a medical emergency.
9. A nurse is preparing to perform a sterile dressing change. Which action
maintains the sterility of the field?
A) Placing sterile items within the 1-inch border of the field
B) Placing sterile items outside the 1-inch border of the field
C) Reaching over the sterile field to retrieve supplies
