Question 1

The nurse is reminding the unlicensed assistive personnel about manifestations of a possible impending seizure.What manifestations does the nurse include? (Select all that apply.)

Accepted Answer

A)   Staring
B)   Rapid eye blinking
C)   Not responding
D)   Sudden fever
E)   Head nodding A, B, C, E

Question 2

The patient is having a generalized tonic-clonic seizure.To maintain the airway, which intervention should the nurse implement after the patient's motor activity ceases?

Accepted Answer

A)   Apply chin-lift position.
B)   Insert a curved oral airway.
C)   Sit the patient in upright position.
D)   Turn the patient to the side. D

Question 3

The Joint Commission restricts the use of restraints to the least restrictive device necessary to prevent disruption of needed care.The order for restraints must include which of the following? (Select all that apply.)

Accepted Answer

A)   Type
B)   Duration
C)   Purpose
D)   Location
E)   Size A, B, C, D

Question 4

A patient at risk for falling is being ambulated.Which action by the nurse is most important to prevent the patient from falling?

Accepted Answer

A)   Raising the bed to an appropriate working height
B)   Placing nonskid shoes on the patient
C)   Dangling the patient on the side of the bed for 10 minutes
D)   Turning on the brightest lights in the room

Question 5

The daughter of a patient tells the nurse that using the bathroom is embarrassing for the patient and she refuses to use a nurse call system when she needs to get up.Which is the best response by the nurse?

Accepted Answer

A)   Ask the patient why she does not use the nurse call system.
B)   Instruct the daughter to remain at the patient's side.
C)   Tell the patient that getting up requires cooperation.
D)   Discuss nurse call system alternatives with patient and daughter.

Question 6

The nurse is caring for a patient who just received a diagnosis of a seizure disorder.What supplies should the nurse gather to have at the bedside? (Select all that apply.)

Accepted Answer

A)   A suction device with catheters
B)   Extra pillows to pad the bed
C)   A padded tongue blade
D)   Oxygen source and nasal cannula
E)   Intubation equipment

Question 7

The nurse plans care for a patient who requires physical restraint.Which is a suitable goal for this patient?

Accepted Answer

A)   The patient remains free of any injury.
B)   The nurse checks the restraint every hour.
C)   The nurse uses the least restrictive restraint.
D)   The patient allows the nurse to apply restraints.

Question 8

A nurse is caring for a child who has frequent seizures.The family does not want the seizures treated and appear to be in awe when they occur.What action by the nurse is best?

Accepted Answer

A)   Inform social services about the noncompliant family.
B)   Teach the family the profound consequences of untreated seizures.
C)   Assess the family's cultural values and norms related to seizures.
D)   Ask the family to leave during a seizure and treat the child then.

Question 9

The nurse is caring for an older patient who has a non-weight-bearing cast on the left lower extremity.The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance.Which response by the nurse is most likely to keep the patient from falling?

Accepted Answer

A)   Apply a vest restraint and offer frequent toileting.
B)   Plan fall prevention with patient, family, and health care provider.
C)   Inform family that the patient needs physical restraints.
D)   Document that the patient has a high potential for falling.

Question 10

The nurse participates in the investigation of an incident in the agency.As a result of the root cause analysis, what would the nurse expect as the ultimate outcome?

Accepted Answer

A)   Identification of the person at fault
B)   An appropriate consequence for the individual at fault
C)   Reason the event occurred
D)   A plan for the prevention of this event

Question 11

A patient has been wandering and is at risk for falling.Which approach by the nurse regarding the use of chemical and physical restraints in the long-term care setting should be considered initially?

Accepted Answer

A)   Use nonprescription restraints first.
B)   Obtain with a telephone prescription.
C)   Implement alternative measures first.
D)   Notify patient's family within 24 hours.

Question 12

Which of the following are examples of alternatives to restraint use in patient care? (Select all that apply.)

Accepted Answer

A)   Frequent observation of patients
B)   Involving patients and families
C)   Frequent reorientation
D)   Four side rails
E)   Wraparound belt with quick release

Question 13

The nurse is caring for a patient and is exposed to a chemotherapy drug during IV administration.Where can the nurse obtain information about the drug that is necessary for an exposure-related incident?

Accepted Answer

A)   The nurse's supervisor
B)   Poison control center
C)   SDS sheets
D)   Employee health services

Question 14

The nurse is instructing a patient who has a difficult-to-control seizure disorder on home care issues.Which issue affecting safety is most important for the nurse to address with patient teaching before discharge?

Accepted Answer

A)   Avoiding substances containing alcohol
B)   Maintaining a current list of medications
C)   Keeping a supply of medications at work
D)   Purchasing lawn equipment with a safety switch

Question 15

After noticing a fire in a patient's room, what action by the nurse takes priority?

Accepted Answer

A)   Yelling for help
B)   Removing the patient from the room
C)   Pulling the fire alarm
D)   Calling security

Question 16

A nurse is assessing a patient after a seizure.What precipitating factors does the nurse consider as possibly causing the seizure? (Select all that apply.)

Accepted Answer

A)   Hypoglycemia
B)   Hypoxia
C)   Alcohol abuse
D)   Electrolyte imbalances
E)   Emotional excitement

Question 17

The nurse plans a restraint-free environment but cannot find activities to engage an agitated middle-aged patient.Which should the nurse implement to maintain the patient's safety?

Accepted Answer

A)   Request help from interdisciplinary team members.
B)   Transfer the patient to a private room to protect others.
C)   Document that the patient is uncooperative and hostile.
D)   Ask the health care provider for a sedation prescription.

Question 18

The nurse plans a fall prevention program for a confused patient.Which task from the program is suitable for the nurse to delegate to nursing assistive personnel (NAP)?

Accepted Answer

A)   Evaluating patient understanding of fall prevention plan
B)   Keeping the patient's bed in the low position at all times
C)   Assessing the patient's circulatory and respiratory status
D)   Instructing the patient's family about alternatives to restraints

Question 19

The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears that the patient will pull them out.Which nursing intervention should the nurse implement to maintain the patient's self-esteem and avoid applying restraints?

Accepted Answer

A)   Cover or camouflage tubes and drains.
B)   Provide constant activity for the patient.
C)   Instruct family members to watch the patient.
D)   Keep the patient close to the nurses' station.

Question 20

The nurse listens to a family's request to bring a few familiar items into the room of a patient who is confused.What response by the nurse is best?

Accepted Answer

A)   No, because personal items can increase patient agitation.
B)   No, because personal items can create too much clutter.
C)   Yes, personal items are likely to restore cognitive function.
D)   Yes, personal items can comfort a confused person.

Exam 4: Patient Safety and Quality Improvement