Question 1

Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.)

Accepted Answer

A)  Conduct hourly rounds. 
B)  Provide the patient regular toileting. 
C)  Assess the patient's comfort needs. 
D)  Evaluate the effectiveness of pain medication. 
A)  Conduct hourly rounds. 
B)  Provide the patient regular toileting. 
C)  Assess the patient's comfort needs. 
D)  Evaluate the effectiveness of pain medication. A,B,C,D

Question 2

To promote patient safety,government standards regarding mechanical and physical restraints state that

Accepted Answer

A)  alternative measures are to be implemented before restraints are used. 
B)  the nurse's judgment is all that is required for restraint use. 
C)  restraints should be used immediately for all patients who may need them. 
D)  restraints cannot be used except to prevent others from being harmed. 
A)  alternative measures are to be implemented before restraints are used. 
B)  the nurse's judgment is all that is required for restraint use. 
C)  restraints should be used immediately for all patients who may need them. 
D)  restraints cannot be used except to prevent others from being harmed. A

Question 3

Continuous seizure activity that lasts longer than 30 minutes is known as _______________.

Accepted Answer

A)  focal onset seizure 
B)  generalized onset seizure 
C)  status epilepticus 
D)  unknown onset seizure 
A)  focal onset seizure 
B)  generalized onset seizure 
C)  status epilepticus 
D)  unknown onset seizure C

Question 4

A thumbless device used to restrain patients' hands to prevent them from dislodging invasive equipment,removing dressings,or scratching is known as a(n)_____________.

Accepted Answer

A)  freedom splint 
B)  mitten restraint 
C)  belt restraint 
D)  extremity restraint 
A)  freedom splint 
B)  mitten restraint 
C)  belt restraint 
D)  extremity restraint

Question 5

When caring for a patient who has an arm or leg restraint in place,how often will the nurse remove the restraint?

Accepted Answer

A)  Every 15 minutes 
B)  Every 30 minutes 
C)  Every hour 
D)  Every 2 hours 
A)  Every 15 minutes 
B)  Every 30 minutes 
C)  Every hour 
D)  Every 2 hours

Question 6

The patient is an older person who is admitted for a medical problem.While doing his admission assessment,the nurse learns that the patient gets up two to three times a night to use the restroom.The institution has only beds with four side rails.Which of the following is the appropriate rationale for leaving one of the lower side rails down?

Accepted Answer

A)  Falls rarely happen in the inpatient setting. 
B)  Having all side rails raised increases the occurrence of falling. 
C)  Side rails have no bearing on whether or not a patient falls. 
D)  Patient falls rarely result in physical injury. 
A)  Falls rarely happen in the inpatient setting. 
B)  Having all side rails raised increases the occurrence of falling. 
C)  Side rails have no bearing on whether or not a patient falls. 
D)  Patient falls rarely result in physical injury.

Question 7

After recognizing that a patient has received an electrical shock and removing the source of the shock,what should the nurse do next?

Accepted Answer

A)  Call for assistance. 
B)  Immediately start cardiopulmonary resuscitation (CPR). 
C)  Obtain emergency equipment. 
D)  Assess for the presence of a pulse. 
A)  Call for assistance. 
B)  Immediately start cardiopulmonary resuscitation (CPR). 
C)  Obtain emergency equipment. 
D)  Assess for the presence of a pulse.

Question 8

Effective fall prevention programs include which of the following? (Select all that apply.)

Accepted Answer

A)  Risk assessment 
B)  Medication reviews 
C)  Use of assistive devices 
D)  Exercise and strength training 
E)  None of the above 
A)  Risk assessment 
B)  Medication reviews 
C)  Use of assistive devices 
D)  Exercise and strength training 
E)  None of the above

Question 9

A patient is taking a medication that has the potential to cause orthostatic hypotension.Which of the following nursing interventions is appropriate for this patient?

Accepted Answer

A)  Have the patient sit slowly and dangle. 
B)  Refer the patient to physical therapy. 
C)  Keep the side rails up at all times. 
D)  Obtain a walker or a cane for patient use. 
A)  Have the patient sit slowly and dangle. 
B)  Refer the patient to physical therapy. 
C)  Keep the side rails up at all times. 
D)  Obtain a walker or a cane for patient use.

Question 10

On entering the patient's room,the nurse sees a fire burning in the trashcan next to the bed.The nurse removes the patient and reports the fire.What is the nurse's next action?

Accepted Answer

A)  Extinguish the fire. 
B)  Remove all other patients from the unit. 
C)  Close all doors of patient rooms. 
D)  Move the trashcan into the bathroom. 
A)  Extinguish the fire. 
B)  Remove all other patients from the unit. 
C)  Close all doors of patient rooms. 
D)  Move the trashcan into the bathroom.

Question 11

When working with a patient who has a new seizure disorder,the nurse is alerted to the need for further instruction when the patient tells the nurse: (Select all that apply.)

Accepted Answer

A)  "I will avoid alcohol because it can react with my medications and make me sleepy." 
B)  "I have the medications that I take listed on this card that I carry with me." 
C)  "I will be sure to take my medications as prescribed by my provider." 
D)  "I will visit my physician right after I return home from my next trucking job." 
A)  "I will avoid alcohol because it can react with my medications and make me sleepy." 
B)  "I have the medications that I take listed on this card that I carry with me." 
C)  "I will be sure to take my medications as prescribed by my provider." 
D)  "I will visit my physician right after I return home from my next trucking job."

Question 12

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

Accepted Answer

A)  Remove the restraint. 
B)  Loosen the restraint. 
C)  Obtain a larger restraint. 
D)  Reapply the restraint with more padding. 
A)  Remove the restraint. 
B)  Loosen the restraint. 
C)  Obtain a larger restraint. 
D)  Reapply the restraint with more padding.

Question 13

A patient is well known to the hospital staff from previous admissions and is prone to wandering at night.For patient safety,the physician writes a prescription for "belt restraint prn." What should the nurse do on reviewing this prescription?

Accepted Answer

A)  Apply a belt restraint on the patient as needed. 
B)  Have the patient sign an informed consent form. 
C)  Inform the physician that prn restraint prescriptions are unacceptable. 
D)  Obtain a signed informed consent from a family member. 
A)  Apply a belt restraint on the patient as needed. 
B)  Have the patient sign an informed consent form. 
C)  Inform the physician that prn restraint prescriptions are unacceptable. 
D)  Obtain a signed informed consent from a family member.

Question 14

When caring for a patient who has been restrained,how often will the nurse perform an assessment?

Accepted Answer

A)  Every 15 minutes 
B)  Every 30 minutes 
C)  Every hour 
D)  Every 2 hours 
A)  Every 15 minutes 
B)  Every 30 minutes 
C)  Every hour 
D)  Every 2 hours

Question 15

Given the most common causes of hospital fires,which of the following choices are most appropriate in preventing patient injury?

Accepted Answer

A)  Ensure that all electrical devices are checked by engineering. 
B)  Assist patients who smoke to a safe area to smoke. 
C)  Prop fire doors open for easier patient access. 
D)  Educate patients on the importance of smoking cessation. 
A)  Ensure that all electrical devices are checked by engineering. 
B)  Assist patients who smoke to a safe area to smoke. 
C)  Prop fire doors open for easier patient access. 
D)  Educate patients on the importance of smoking cessation.

Question 16

A nurse enters the room of a patient who is sitting in a chair and the patient begins to have a seizure.To promote patient safety,which nursing intervention will the nurse initially perform?

Accepted Answer

A)  Immediately call for assistance. 
B)  Assist the patient to the floor. 
C)  Put the patient back into the bed. 
D)  Insert a padded tongue blade into the patient's mouth. 
A)  Immediately call for assistance. 
B)  Assist the patient to the floor. 
C)  Put the patient back into the bed. 
D)  Insert a padded tongue blade into the patient's mouth.

Question 17

What should the nurse do to promote patient understanding and security in the health care setting?

Accepted Answer

A)  Restrain the patient as necessary. 
B)  Explain all procedures to the patient. 
C)  Allow the patient more time alone. 
D)  Restrict activity as much as possible. 
A)  Restrain the patient as necessary. 
B)  Explain all procedures to the patient. 
C)  Allow the patient more time alone. 
D)  Restrict activity as much as possible.

Question 18

Which of the following alternatives to physical restraints should the nurse use to promote patient safety? (Select all that apply.)

Accepted Answer

A)  Environmental modifications 
B)  Less frequent patient observation 
C)  Involvement of family during visitation 
D)  Frequent reorientation of the patient 
A)  Environmental modifications 
B)  Less frequent patient observation 
C)  Involvement of family during visitation 
D)  Frequent reorientation of the patient

Question 19

What should the nurse do to prevent a patient from aspirating during a seizure?

Accepted Answer

A)  Insert an oral airway. 
B)  Restrain the patient securely. 
C)  Sit the patient upright. 
D)  Turn the patient onto his or her side. 
A)  Insert an oral airway. 
B)  Restrain the patient securely. 
C)  Sit the patient upright. 
D)  Turn the patient onto his or her side.

Question 20

The use of restraints has been associated with which of the following complications? (Select all that apply.)

Accepted Answer

A)  Pressure injuries 
B)  Pneumonia 
C)  Constipation 
D)  Death 
A)  Pressure injuries 
B)  Pneumonia 
C)  Constipation 
D)  Death

Exam 14: Patient Safety

Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.)

To promote patient safety,government standards regarding mechanical and physical restraints state that

Continuous seizure activity that lasts longer than 30 minutes is known as _______________.

A thumbless device used to restrain patients' hands to prevent them from dislodging invasive equipment,removing dressings,or scratching is known as a(n)_____________.

When caring for a patient who has an arm or leg restraint in place,how often will the nurse remove the restraint?

After recognizing that a patient has received an electrical shock and removing the source of the shock,what should the nurse do next?

Effective fall prevention programs include which of the following? (Select all that apply.)

A patient is taking a medication that has the potential to cause orthostatic hypotension.Which of the following nursing interventions is appropriate for this patient?

On entering the patient's room,the nurse sees a fire burning in the trashcan next to the bed.The nurse removes the patient and reports the fire.What is the nurse's next action?

When working with a patient who has a new seizure disorder,the nurse is alerted to the need for further instruction when the patient tells the nurse: (Select all that apply.)

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

A patient is well known to the hospital staff from previous admissions and is prone to wandering at night.For patient safety,the physician writes a prescription for "belt restraint prn." What should the nurse do on reviewing this prescription?

When caring for a patient who has been restrained,how often will the nurse perform an assessment?

Given the most common causes of hospital fires,which of the following choices are most appropriate in preventing patient injury?

A nurse enters the room of a patient who is sitting in a chair and the patient begins to have a seizure.To promote patient safety,which nursing intervention will the nurse initially perform?

What should the nurse do to promote patient understanding and security in the health care setting?

Which of the following alternatives to physical restraints should the nurse use to promote patient safety? (Select all that apply.)

What should the nurse do to prevent a patient from aspirating during a seizure?

The use of restraints has been associated with which of the following complications? (Select all that apply.)

Evidence-Informed Nursing Practice

Transitions in Care

Communication and Collaboration

Documentation and Informatics

Medical Asepsis

Sterile Technique

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Emergency Preparedness and Disaster Management

Pain Assessment and Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Nonparenteral Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Vascular Access and Infusion Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination and Catheterization

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Prevention and Care of Skin Breakdown

Wound Care Management and Dressings

Therapeutic Use of Heat and Cold

Safety in the Community

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