Nurs 100 Fundamentals Exam 2 UPDATED
QUESTIONS AND CORRECT ANSWERS
1. A nurse is caring for a client who has a history of falls. Which of the following actions is
the nurse's
priority?
a. Complete a fall risk assessment
b. Educate the client and family about fall risks
c. Eliminate safety hazards from the client's environment
d. Make sure the client uses assistive aids in his possession - CORRECT ANSWER a.
Complete a fall risk assessment
you should position the patient's head of bed at ____ degrees
a. more than 40
b. 90 angle
c. less than 30
d. any position - CORRECT ANSWER c. less than 30
Fall prevention interventions - CORRECT ANSWER •Bathtub with rails or shower
seat
• Raised toilet seats• Night lights
• Remove clutter
• Remove rugs
• Non-slip socks
• Fall risk band
• Bed locked and in lowest position
restrains padding goes on - CORRECT ANSWER boney promient
for restrains you always need a ________ - CORRECT ANSWER ORDER
, T/F: what a patient is confused, the nurse should do all he can before placing the patient in
restraints - CORRECT ANSWER True
2. A nurse is caring for a client who fell at a nursing home. The client is oriented to person,
place, and
time, and can follow directions. Which of the following actions should the nurse take to
decrease
the risk of another fall? (Select all that apply)
a. Place a belt restraint on the client when he is sitting on the bedside commode
b. Keep the bed in its lowest position with all side rails up
c. Make sure that the client's call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall risk assessment - CORRECT ANSWER c. Make sure that the client's
call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall risk assessment
THE FIVE P'S OF PURPOSEFUL ROUNDING - CORRECT ANSWER •Pain
•Potty
•Possessions
•Path
•Plugs
To order a restraint: - CORRECT ANSWER 1) document- behavior exhibited-- why
you need the restraint
2) clients level of conciousness - disorented etc.
3) type of restraint
4) location
QUESTIONS AND CORRECT ANSWERS
1. A nurse is caring for a client who has a history of falls. Which of the following actions is
the nurse's
priority?
a. Complete a fall risk assessment
b. Educate the client and family about fall risks
c. Eliminate safety hazards from the client's environment
d. Make sure the client uses assistive aids in his possession - CORRECT ANSWER a.
Complete a fall risk assessment
you should position the patient's head of bed at ____ degrees
a. more than 40
b. 90 angle
c. less than 30
d. any position - CORRECT ANSWER c. less than 30
Fall prevention interventions - CORRECT ANSWER •Bathtub with rails or shower
seat
• Raised toilet seats• Night lights
• Remove clutter
• Remove rugs
• Non-slip socks
• Fall risk band
• Bed locked and in lowest position
restrains padding goes on - CORRECT ANSWER boney promient
for restrains you always need a ________ - CORRECT ANSWER ORDER
, T/F: what a patient is confused, the nurse should do all he can before placing the patient in
restraints - CORRECT ANSWER True
2. A nurse is caring for a client who fell at a nursing home. The client is oriented to person,
place, and
time, and can follow directions. Which of the following actions should the nurse take to
decrease
the risk of another fall? (Select all that apply)
a. Place a belt restraint on the client when he is sitting on the bedside commode
b. Keep the bed in its lowest position with all side rails up
c. Make sure that the client's call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall risk assessment - CORRECT ANSWER c. Make sure that the client's
call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall risk assessment
THE FIVE P'S OF PURPOSEFUL ROUNDING - CORRECT ANSWER •Pain
•Potty
•Possessions
•Path
•Plugs
To order a restraint: - CORRECT ANSWER 1) document- behavior exhibited-- why
you need the restraint
2) clients level of conciousness - disorented etc.
3) type of restraint
4) location
