Rasmussen University NUR 2243 Module 3 (pdf) | 2026/2027 | Prof
Nursing Skills I Q&A | Nursing
1. A nurse is preparing to apply a mitt restraint to a client. Which action is
most important for the nurse to perform first?
A) Secure the restraint to the bed frame with a quick-release knot
B) Assess the skin integrity and circulation of the hand and wrist
C) Position the client's hand palm-down in the restraint
D) Ensure enough room for one to two fingers to slide between the restraint
and the client
Correct Answer: Assess the skin integrity and circulation of the hand and
wrist
Rationale: Before applying any restraint, the nurse must inspect the area
where the restraint will be applied to assess skin integrity, circulation, range
of motion, and the presence of IV lines or other devices. This is a critical
safety step to prevent injury.
2. A client has a vest restraint applied. Which action by the nurse indicates
correct use of this device?
A) Securing the vest to the side rails of the bed
B) Tying the vest straps with a double knot to prevent accidental release
C) Using a quick-release knot to secure the straps to the bed frame
D) Keeping the vest snug against the client's chest with no room to move
Correct Answer: Using a quick-release knot to secure the straps to the bed
frame
,Rationale: Restraint straps must be secured to the bed frame, not the side
rails, 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.
3. A client is in a wrist restraint. How often must the nurse assess the client's
circulation and skin integrity?
A) Every 2 hours
B) Every 4 hours
C) Every 8 hours
D) At the beginning of each shift
Correct Answer: Every 2 hours
Rationale: Clients in restraints must be assessed at least every 2 hours for
circulation, skin integrity, and comfort. The nurse must also reassess and
readjust restraints as indicated.
4. A nurse is caring for an older adult client who is at risk for falls. Which
intervention should the nurse implement before considering restraints?
A) Place the client in a high-risk fall zone and check every 4 hours
B) Apply a vest restraint to prevent the client from getting out of bed
C) Initiate a toileting schedule and use bed or chair alarms
D) Keep the client's bed in the highest position to deter mobility
Correct Answer: Initiate a toileting schedule and use bed or chair alarms
Rationale: Restraints should be a last resort. Alternatives include toileting
schedules, bed or chair alarms, and keeping the bed in the lowest position.
These measures address the underlying cause of falls (e.g., toileting needs)
without restricting movement.
,5. 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, such as
sequential compression devices and anticoagulants, and monitor for signs of
thrombosis.
6. A client who has been on bed rest for 3 days suddenly develops shortness
of breath and chest pain. The nurse should suspect which complication?
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.
, 7. A nurse is performing passive range-of-motion (ROM) exercises on a client
who is immobile. Which principle should the nurse follow?
A) Move the joint to the point of pain and then slightly further
B) Support the extremity above and below the joint being exercised
C) Perform exercises quickly to minimize discomfort
D) Only perform ROM exercises on the upper extremities
Correct Answer: Support the extremity above and below the joint being
exercised
Rationale: When performing passive ROM, the nurse should support the
extremity above and below the joint to prevent strain and injury. The joint
should be moved to the point of resistance, not pain, and exercises should be
performed slowly and smoothly.
8. A client with a spinal cord injury at the T4 level is at risk for autonomic
dysreflexia. Which symptom is most characteristic of this condition?
A) Hypotension and tachycardia
B) Hypertension and bradycardia
C) Hypotension and bradycardia
D) Flaccid paralysis of the lower extremities
Correct Answer: Hypertension and bradycardia
Rationale: Autonomic dysreflexia is a life-threatening condition characterized
by severe hypertension (systolic BP may exceed 200 mm Hg) and reflex
bradycardia (30-40 bpm). It is a medical emergency requiring immediate
intervention.
Nursing Skills I Q&A | Nursing
1. A nurse is preparing to apply a mitt restraint to a client. Which action is
most important for the nurse to perform first?
A) Secure the restraint to the bed frame with a quick-release knot
B) Assess the skin integrity and circulation of the hand and wrist
C) Position the client's hand palm-down in the restraint
D) Ensure enough room for one to two fingers to slide between the restraint
and the client
Correct Answer: Assess the skin integrity and circulation of the hand and
wrist
Rationale: Before applying any restraint, the nurse must inspect the area
where the restraint will be applied to assess skin integrity, circulation, range
of motion, and the presence of IV lines or other devices. This is a critical
safety step to prevent injury.
2. A client has a vest restraint applied. Which action by the nurse indicates
correct use of this device?
A) Securing the vest to the side rails of the bed
B) Tying the vest straps with a double knot to prevent accidental release
C) Using a quick-release knot to secure the straps to the bed frame
D) Keeping the vest snug against the client's chest with no room to move
Correct Answer: Using a quick-release knot to secure the straps to the bed
frame
,Rationale: Restraint straps must be secured to the bed frame, not the side
rails, 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.
3. A client is in a wrist restraint. How often must the nurse assess the client's
circulation and skin integrity?
A) Every 2 hours
B) Every 4 hours
C) Every 8 hours
D) At the beginning of each shift
Correct Answer: Every 2 hours
Rationale: Clients in restraints must be assessed at least every 2 hours for
circulation, skin integrity, and comfort. The nurse must also reassess and
readjust restraints as indicated.
4. A nurse is caring for an older adult client who is at risk for falls. Which
intervention should the nurse implement before considering restraints?
A) Place the client in a high-risk fall zone and check every 4 hours
B) Apply a vest restraint to prevent the client from getting out of bed
C) Initiate a toileting schedule and use bed or chair alarms
D) Keep the client's bed in the highest position to deter mobility
Correct Answer: Initiate a toileting schedule and use bed or chair alarms
Rationale: Restraints should be a last resort. Alternatives include toileting
schedules, bed or chair alarms, and keeping the bed in the lowest position.
These measures address the underlying cause of falls (e.g., toileting needs)
without restricting movement.
,5. 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, such as
sequential compression devices and anticoagulants, and monitor for signs of
thrombosis.
6. A client who has been on bed rest for 3 days suddenly develops shortness
of breath and chest pain. The nurse should suspect which complication?
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.
, 7. A nurse is performing passive range-of-motion (ROM) exercises on a client
who is immobile. Which principle should the nurse follow?
A) Move the joint to the point of pain and then slightly further
B) Support the extremity above and below the joint being exercised
C) Perform exercises quickly to minimize discomfort
D) Only perform ROM exercises on the upper extremities
Correct Answer: Support the extremity above and below the joint being
exercised
Rationale: When performing passive ROM, the nurse should support the
extremity above and below the joint to prevent strain and injury. The joint
should be moved to the point of resistance, not pain, and exercises should be
performed slowly and smoothly.
8. A client with a spinal cord injury at the T4 level is at risk for autonomic
dysreflexia. Which symptom is most characteristic of this condition?
A) Hypotension and tachycardia
B) Hypertension and bradycardia
C) Hypotension and bradycardia
D) Flaccid paralysis of the lower extremities
Correct Answer: Hypertension and bradycardia
Rationale: Autonomic dysreflexia is a life-threatening condition characterized
by severe hypertension (systolic BP may exceed 200 mm Hg) and reflex
bradycardia (30-40 bpm). It is a medical emergency requiring immediate
intervention.
