NUR 216 Exam 3 Actual All Accurately Answered |
Complete Questions & Rationales | Nursing
Concepts | Pass Guaranteed - A+ Graded
Patient Safety & Infection Control
Q1: A 78-year-old patient admitted for hip replacement is ambulating with a walker for
the first time post-op. Using the Morse Fall Scale, which factor would contribute the
MOST points to his fall risk score?
A. The patient has an IV infusion running
B. The patient uses a walker
C. The patient has a history of falls [CORRECT]
D. The patient is on a diuretic
Correct Answer: C
Rationale: On the Morse Fall Scale, a history of falls is one of the highest weighted
factors because previous falls are the strongest predictor of future falls. That is why we
always ask about fall history during admission assessments.
Q2: During evening rounds, the nurse finds a patient lying on the floor next to the bed.
The patient is alert and oriented, complaining of right wrist pain but denies hitting his
head. What is the nurse's FIRST priority action?
A. Complete a full head-to-toe assessment and document the incident
B. Help the patient back into bed and apply ice to the wrist
C. Assess for injuries and call for assistance using proper lifting equipment [CORRECT]
D. Notify the provider and family immediately before moving the patient
Correct Answer: C
,Rationale: After a fall, your first job is to assess the patient for injuries and get help to
move him safely. You do not just yank him off the floor without checking for fractures or
spinal injuries first.
Q3: An agitated patient with dementia keeps trying to pull out his feeding tube. The
nurse has tried redirection, a sitter, and increasing activities, but the behavior continues.
What is the most appropriate next step?
A. Apply bilateral wrist restraints to prevent tube removal
B. Apply a mitten restraint on the dominant hand only
C. Consult the provider and consider a less restrictive alternative such as a mitten or
elbow restraint while continuing non-restraint interventions [CORRECT]
D. Sedate the patient with PRN antipsychotics without further assessment
Correct Answer: C
Rationale: Restraints should always be the last resort after you have tried every less
restrictive option. If they become necessary, you need a provider's order and you keep
looking for alternatives while they are in place.
Q4: A patient is in bilateral wrist restraints per provider order due to repeated attempts
to remove his central line. How often must the nurse assess and document circulation
and skin integrity?
A. Every 15 minutes
B. Every 30 minutes
C. Every 1 to 2 hours [CORRECT]
D. Every 4 hours
Correct Answer: C
Rationale: For non-violent restraints, the standard is to check circulation and skin
integrity every one to two hours and to release the restraints and reposition the patient
at least every two hours. That protects both safety and dignity.
Q5: A nurse discovers that a patient received the wrong antibiotic due to a medication
administration error that resulted in significant harm requiring additional treatment. This
event meets the definition of a:
A. Near-miss event
B. Sentinel event [CORRECT]
, C. Expected outcome
D. Variance report
Correct Answer: B
Rationale: A sentinel event is an unexpected occurrence involving death or serious
physical or psychological injury, and medication errors causing significant harm fall into
that category. These events trigger a root cause analysis and reporting to leadership.
Q6: After a patient fall resulting in a fractured hip, the unit manager reviews the incident
report, interviews staff, examines the call light system, and discovers the bed alarm was
not functioning. The team then revises the equipment check protocol. This process is
best described as:
A. Quality improvement audit
B. Peer review
C. Root cause analysis [CORRECT]
D. Variance report
Correct Answer: C
Rationale: Root cause analysis is a structured method used to dig deep into what
happened, why it happened, and how to fix the system so it does not happen again. It is
not about blaming individuals; it is about fixing the process.
Q7: In the chain of infection, a contaminated stethoscope that is used on multiple
patients without cleaning represents which link?
A. Reservoir
B. Portal of exit
C. Mode of transmission [CORRECT]
D. Portal of entry
Correct Answer: C
Rationale: A contaminated stethoscope acts as a fomite, which is an indirect mode of
transmission that carries pathogens from one patient to another. That is why we clean
our equipment between every patient contact.
Complete Questions & Rationales | Nursing
Concepts | Pass Guaranteed - A+ Graded
Patient Safety & Infection Control
Q1: A 78-year-old patient admitted for hip replacement is ambulating with a walker for
the first time post-op. Using the Morse Fall Scale, which factor would contribute the
MOST points to his fall risk score?
A. The patient has an IV infusion running
B. The patient uses a walker
C. The patient has a history of falls [CORRECT]
D. The patient is on a diuretic
Correct Answer: C
Rationale: On the Morse Fall Scale, a history of falls is one of the highest weighted
factors because previous falls are the strongest predictor of future falls. That is why we
always ask about fall history during admission assessments.
Q2: During evening rounds, the nurse finds a patient lying on the floor next to the bed.
The patient is alert and oriented, complaining of right wrist pain but denies hitting his
head. What is the nurse's FIRST priority action?
A. Complete a full head-to-toe assessment and document the incident
B. Help the patient back into bed and apply ice to the wrist
C. Assess for injuries and call for assistance using proper lifting equipment [CORRECT]
D. Notify the provider and family immediately before moving the patient
Correct Answer: C
,Rationale: After a fall, your first job is to assess the patient for injuries and get help to
move him safely. You do not just yank him off the floor without checking for fractures or
spinal injuries first.
Q3: An agitated patient with dementia keeps trying to pull out his feeding tube. The
nurse has tried redirection, a sitter, and increasing activities, but the behavior continues.
What is the most appropriate next step?
A. Apply bilateral wrist restraints to prevent tube removal
B. Apply a mitten restraint on the dominant hand only
C. Consult the provider and consider a less restrictive alternative such as a mitten or
elbow restraint while continuing non-restraint interventions [CORRECT]
D. Sedate the patient with PRN antipsychotics without further assessment
Correct Answer: C
Rationale: Restraints should always be the last resort after you have tried every less
restrictive option. If they become necessary, you need a provider's order and you keep
looking for alternatives while they are in place.
Q4: A patient is in bilateral wrist restraints per provider order due to repeated attempts
to remove his central line. How often must the nurse assess and document circulation
and skin integrity?
A. Every 15 minutes
B. Every 30 minutes
C. Every 1 to 2 hours [CORRECT]
D. Every 4 hours
Correct Answer: C
Rationale: For non-violent restraints, the standard is to check circulation and skin
integrity every one to two hours and to release the restraints and reposition the patient
at least every two hours. That protects both safety and dignity.
Q5: A nurse discovers that a patient received the wrong antibiotic due to a medication
administration error that resulted in significant harm requiring additional treatment. This
event meets the definition of a:
A. Near-miss event
B. Sentinel event [CORRECT]
, C. Expected outcome
D. Variance report
Correct Answer: B
Rationale: A sentinel event is an unexpected occurrence involving death or serious
physical or psychological injury, and medication errors causing significant harm fall into
that category. These events trigger a root cause analysis and reporting to leadership.
Q6: After a patient fall resulting in a fractured hip, the unit manager reviews the incident
report, interviews staff, examines the call light system, and discovers the bed alarm was
not functioning. The team then revises the equipment check protocol. This process is
best described as:
A. Quality improvement audit
B. Peer review
C. Root cause analysis [CORRECT]
D. Variance report
Correct Answer: C
Rationale: Root cause analysis is a structured method used to dig deep into what
happened, why it happened, and how to fix the system so it does not happen again. It is
not about blaming individuals; it is about fixing the process.
Q7: In the chain of infection, a contaminated stethoscope that is used on multiple
patients without cleaning represents which link?
A. Reservoir
B. Portal of exit
C. Mode of transmission [CORRECT]
D. Portal of entry
Correct Answer: C
Rationale: A contaminated stethoscope acts as a fomite, which is an indirect mode of
transmission that carries pathogens from one patient to another. That is why we clean
our equipment between every patient contact.
