Mobility, Positioning, and Vital Signs Skill Tasks

A Note on Hand Hygiene for These Tasks

Every task in this section is a randomly selected task, so 'perform hand hygiene' at the start and end means alcohol-based hand sanitizer: cover all surfaces of the hands and rub until completely dry. The full soap-and-water wash belongs only to the four mandatory tasks.

Transfers with a Gait Belt (Bed to Wheelchair)

Montana's transfer checklist differs from the generic version taught in many textbooks, and the difference is worth points.

After hand hygiene, obtain a gait belt and explain the procedure. Position the wheelchair at the foot or head of the bed — Montana does not score a 45-degree angle or a strong-side placement — and lock the wheelchair brakes. Bring the resident to a sitting position using correct body mechanics, then position the bed to a height where the resident's feet are flat on the floor while sitting on the edge. Assist the resident into shoes or non-skid slippers.

Place the gait belt around the waist, tighten it, and check it by slipping your fingers between the belt and the resident. Then stand in front of and face the resident, grasp the belt on each side with an underhand grip, and use your legs to stabilize the resident. Bring the resident to standing with correct body mechanics. With one hand on the gait belt and the other stabilizing the resident by the forearm, shoulder, or another appropriate hold, transfer them to the wheelchair and assist the pivot and the sit in a controlled manner. Remove the gait belt. Call light in reach, hand hygiene.

Transfer from Wheelchair to Bed

Same opening: hand hygiene, gait belt, explain, wheelchair at the foot or head of the bed, brakes locked, bed set so the feet will be flat on the floor. Belt on, tightened, checked with your fingers. Stand in front of and face the resident, then two instruction steps Montana scores explicitly: instruct the resident to move their hips forward to the front of the wheelchair seat, and instruct the resident to place their hands on the wheelchair armrests. Use your legs to stabilize, assist to standing with an underhand grip on the belt, assist the pivot in a controlled manner, and assist the resident to sit on the bed. Remove the gait belt, remove the footwear, and assist the resident to the center of the bed and lying down with proper body mechanics, comfortable and in good alignment.

Ambulate with a Gait Belt

This task ends at a wheelchair, not in open hallway. Hand hygiene, obtain the belt, explain, position the bed so the feet will be flat on the floor, lock the wheelchair brakes, bring the resident to sitting, and put on shoes or non-skid slippers. Belt on, tightened, fingers checked. Stand in front of and face the resident, grasp the belt on each side with an underhand grip, stabilize with your legs, and bring them to standing with correct body mechanics. With one hand on the belt and the other stabilizing the forearm or shoulder, ambulate the resident at least 10 steps to the wheelchair, assist them to pivot or back up to it, and assist a controlled sit. Remove the gait belt.

If a resident's knees buckle during real ambulation, do not try to hold them up: use the belt to ease them down along your leg, protect the head, stay with them, and call for the nurse.

Ambulate with a Cane or Walker

Same framework, no belt. Position the bed so the feet will be flat on the floor, lock the wheelchair brakes, bring the resident to sitting, and put on shoes or non-skid slippers. Position the cane or walker correctly, assist the resident to stand with correct body mechanics, and ensure the resident stabilizes the cane or walker before moving. Then position yourself behind and slightly to the side of the resident and safely ambulate at least 10 steps to the wheelchair, assist the pivot or back-up, and assist a controlled sit.

The device technique itself is knowledge-exam material and worth knowing cold: a cane is held on the strong side and advances with the weak leg — 'cane, weak, strong'. With a walker, the resident stands inside the frame, the walker advances first, then the weak leg, then the strong leg, with all four legs on the floor before weight is taken.

Position a Resident on Their Side in Bed

Montana's version of this task is specific, and it does not use a logroll. After hand hygiene, explain the procedure and how the resident may help, provide privacy, position the bed flat, adjust it to a comfortable working height, and lock the bed brakes.

Move the resident toward yourself in three scored stages — the torso, then the hips, then the legs — either with a turn sheet and weight-shift technique or by moving them with proper body mechanics. Cross the resident's legs. Then turn the resident onto the side named in the scenario: either turn them toward the RN Test Observer from your working side, or move to the opposite side of the bed and turn them toward yourself. Listen to the scenario for which side.

Finally, place four support devices:

• under the head
• under the up-side arm
• behind the back
• between the knees

Lower the bed, call light in reach, hand hygiene.

Range of Motion Exercises

Position the resident supine and in good body alignment, provide privacy, and correctly support the extremity or joint being exercised. Then work the joints in order, each at least three times:

One step spans the whole task: do not cause discomfort or pain, and do not force any joint beyond the point of free movement. If the resident winces, stop there, keep the limb supported, and report it to the nurse.

Apply an Anti-Embolic Stocking (One Leg)

Anti-embolic stockings promote venous return and help prevent clots. Provide privacy by exposing only one leg. Roll, gather, or turn the stocking down to the heel, gently place it over the toes, foot, and heel, and gently roll or pull it up the leg. Check the toes for possible pressure from the stocking and adjust as needed. Leave the stocking smooth and wrinkle-free and properly placed — wrinkles create pressure points that break down skin — then cover the resident's exposed leg before you finish.

Make a Resident's Occupied Bed

Gather the linen, transport it away from your body, and place clean linen on a clean surface (bedside stand, chair, or barrier). Explain, provide privacy, and raise the bed to a comfortable working height. Keep the resident covered with the sheet at all times; remove the top linen except that sheet, and gently remove the pillow.

Here is the Montana-specific safety step: ask the RN Test Observer to stand on the opposite side of the bed to provide safety while you turn the resident toward that side. Roll or fan-fold the soiled linen soiled side inside to the center, place the clean bottom sheet along the center, fan-fold it against the resident's back, unfold the remaining half, and pull the corners tight and tuck securely under the mattress. Ask the observer to move to the opposite side, then assist the resident to roll over the bottom linen toward the observer without causing trauma or avoidable pain.

Remove the soiled linen without shaking it, keeping it off the overbed table and away from your uniform, and place it in the hamper. Pull the clean linen through and smooth it, place the clean top linen over the covered resident, remove the remaining soiled linen while keeping the resident unexposed, tuck the top linen, and make toe pleats. Apply a clean pillowcase with the zippers or tags turned to the inside, gently lift the head to replace the pillow, lower the bed, and leave the resident comfortable and safe in a neatly made bed with the call light in reach.

The Three Vital Signs Tasks

All three end with a recorded number that is compared against the observer's.

Manual blood pressure. Assist the resident into a comfortable position with the forearm relaxed and supported palm-up at about heart level, and roll the sleeve up about 5 inches above the elbow if the actor is wearing sleeves. Apply the cuff around the upper arm just above the elbow. Clean the stethoscope earpieces appropriately and place them in your ears, then clean the diaphragm — two separate scored steps that candidates skip when they are rushing. Locate the brachial artery with your fingertips just above the bend of the elbow, place the stethoscope over it, and hold it snugly in place. Inflate the cuff, then slowly release the air until the pulsations disappear, remove the cuff, and record. Tolerance: within 4 mm Hg on both the systolic and diastolic. In everyday practice the first clear sound is the systolic and the point the sounds disappear is the diastolic; a cuff that is too small reads falsely high, and one that is too large reads falsely low.

Radial pulse and respirations. Locate the radial pulse by placing the tips of your fingers on the thumb side of the wrist — never your thumb, which has a pulse of its own. Count the pulse for 60 seconds, or for 30 seconds and multiply by two; record it within 4 beats. Then count respirations for 60 seconds, or 30 seconds times two; record within 2 breaths. Count respirations without announcing that you are doing so — keep your fingers on the wrist as though the pulse check were continuing, because people change their breathing when they know it is being measured.

Temperature, radial pulse, and respirations. Montana allows a digital, tympanic, or temp-dot thermometer. Turn on or correctly handle the device, place it appropriately (bulb under the tongue, tympanic in the ear, or temp dot properly placed), hold or leave it in place for the appropriate length of time, remove it, and record — within 0.1 degree. Then wipe the thermometer with an alcohol pad, or discard the sheath or temp dot appropriately, before moving on to the pulse and respirations exactly as above.

The Ending Steps That Decide Close Tasks

Before you walk away from any task in this section, run the list: brakes locked (or unlocked, on the weighing task), bed lowered, resident comfortable and in good alignment, call light within easy reach, hand hygiene performed. Observers score these on nearly every checklist, and they are the cheapest points to lose when the 35-minute clock is running.