NUR 02 FUNDAMENTALS EXAM 6
,1-A nurse has received report from the off-going shift that a client is confused and has been identified
as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel
(UAP). Which finding by the nurse requires intervention?
1. UAP has attached a bed alarm to the client's gown and bed
2. UAP has been making hourly rounds on the client
3. UAP has lowered the bed and raised all 4 side rails
4. UAP has placed a fall risk ID bracelet on the client's wrist
Explanation:
Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a
form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try
to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least
one side rail and communicate to the UAP that having all 4 up is inappropriate.
(Option 1) Placing a bed alarm would be an appropriate intervention for this client.
(Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if
more frequent rounds are warranted.
(Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary
team that the client is at risk for falls.
Educational objective:
The nurse should ensure that multiple interventions are put in place for the client at high risk for falls.
These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a
fall risk ID band, using bed alarms, and making frequent rounds on the client.
2-Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants
the nurse's intervention first?
1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake
2. Room 2: Client and family request clergy to administer last rites
3. Room 3: Puncture-resistant sharps disposal container on the wall is full
4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4
mmol/L)
Explanation:
Health care workers are required to abide by Occupational Safety and Health Administration
standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne
pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and
should be replaced on a regular basis to reduce the risk for a needle stick during disposal.
(Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must
be restarted. A new container will need to be labeled with the appropriate times and date, but
immediate intervention is not required.
,(Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the
Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although
the situation requires prompt intervention, it does not involve a safety hazard.
(Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L])
and requires no intervention unless the client received insulin and refuses or is unable to eat.
Educational objective:
Prevention of injury and safety in the workplace should be a priority when the nurse is delegating,
planning, or providing nursing care.
3-A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s)
should the nurse implement to reduce the incidence of catheter-associated urinary tract infections
(UTIs)? Select all that apply.
1. Cleanse periurethral area with antiseptics every shift
2. Ensure each client has a separate container to empty collection
bag
3. Keep catheter bag below the level of the bladder
4. Routinely irrigate the catheter with antimicrobial solution
5. Use sterile technique when collecting a urine specimen
Explanation:
Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary
catheters. Steps to prevent infections in clients with urinary catheters include the following:
• Wash hands thoroughly and regularly
• Perform routine perineal hygiene with soap and water each shift and after bowel
movements
• Keep drainage system off the floor or contaminated surfaces
• Keep the catheter bag below the level of the bladder
• Ensure each client has a separate, clean container to empty collection bag and measure
urine
• Use sterile technique when collecting a urine specimen
• Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or
backflow into the bladder
• Avoid prolonged kinking, clamping, or obstruction of the catheter tubing
• Encourage oral fluid intake in clients who are awake and if not contraindicated
• Secure the catheter in accordance with hospital policy (tape or Velcro device)
• Inspect the catheter and tubing for integrity, secure connections, and possible kinks
(Option 1) Perineal hygiene is performed using soap and water only every shift and as needed.
Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the
development of drug-resistant bacteria.
(Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is
not recommended for routine catheter care and infection prevention.
Educational objective:
Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene,
, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder
and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag,
and using sterile technique when collecting urine specimens.
4-A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the
emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines
in my top dresser drawer." Which is the best response by the nurse?
1. "Can you lock your dresser drawer?"
2. "Make sure all of your medicines have childproof
caps."
3. "That sounds like a safe plan."
4. "You need to keep an eye on your child at all times."
Explanation:
Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like
many over-the-counter cold products. They usually find medicines when exploring their environment
and "getting into everything" when no one is watching. Children may find medicine in a parent's coat
pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that
seems out of reach, children can climb on a chair or stool to reach it.
Medications are the leading cause of child poisoning. The best preventive measures include placing
all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting
them away after each use (Option 1).
(Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an
appropriate instruction; however, it is not the priority response in this situation.
(Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked.
(Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day,
toddlers need adult supervision when active and exploring their environment.
Educational objective:
The most important strategy to prevent accidental drug overdoses in children is teaching parents and
caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should
also be advised to put drugs away after each use.
5-The nurse recognizes that which factors place a client at increased risk for falls? Select all that
apply.
Age of 50
1.
Diagnosis of ovarian cancer
2.
Lying pulse 80/min, standing pulse 110/min
3.
Osteoarthritis of knees
,1-A nurse has received report from the off-going shift that a client is confused and has been identified
as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel
(UAP). Which finding by the nurse requires intervention?
1. UAP has attached a bed alarm to the client's gown and bed
2. UAP has been making hourly rounds on the client
3. UAP has lowered the bed and raised all 4 side rails
4. UAP has placed a fall risk ID bracelet on the client's wrist
Explanation:
Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a
form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try
to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least
one side rail and communicate to the UAP that having all 4 up is inappropriate.
(Option 1) Placing a bed alarm would be an appropriate intervention for this client.
(Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if
more frequent rounds are warranted.
(Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary
team that the client is at risk for falls.
Educational objective:
The nurse should ensure that multiple interventions are put in place for the client at high risk for falls.
These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a
fall risk ID band, using bed alarms, and making frequent rounds on the client.
2-Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants
the nurse's intervention first?
1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake
2. Room 2: Client and family request clergy to administer last rites
3. Room 3: Puncture-resistant sharps disposal container on the wall is full
4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4
mmol/L)
Explanation:
Health care workers are required to abide by Occupational Safety and Health Administration
standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne
pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and
should be replaced on a regular basis to reduce the risk for a needle stick during disposal.
(Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must
be restarted. A new container will need to be labeled with the appropriate times and date, but
immediate intervention is not required.
,(Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the
Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although
the situation requires prompt intervention, it does not involve a safety hazard.
(Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L])
and requires no intervention unless the client received insulin and refuses or is unable to eat.
Educational objective:
Prevention of injury and safety in the workplace should be a priority when the nurse is delegating,
planning, or providing nursing care.
3-A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s)
should the nurse implement to reduce the incidence of catheter-associated urinary tract infections
(UTIs)? Select all that apply.
1. Cleanse periurethral area with antiseptics every shift
2. Ensure each client has a separate container to empty collection
bag
3. Keep catheter bag below the level of the bladder
4. Routinely irrigate the catheter with antimicrobial solution
5. Use sterile technique when collecting a urine specimen
Explanation:
Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary
catheters. Steps to prevent infections in clients with urinary catheters include the following:
• Wash hands thoroughly and regularly
• Perform routine perineal hygiene with soap and water each shift and after bowel
movements
• Keep drainage system off the floor or contaminated surfaces
• Keep the catheter bag below the level of the bladder
• Ensure each client has a separate, clean container to empty collection bag and measure
urine
• Use sterile technique when collecting a urine specimen
• Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or
backflow into the bladder
• Avoid prolonged kinking, clamping, or obstruction of the catheter tubing
• Encourage oral fluid intake in clients who are awake and if not contraindicated
• Secure the catheter in accordance with hospital policy (tape or Velcro device)
• Inspect the catheter and tubing for integrity, secure connections, and possible kinks
(Option 1) Perineal hygiene is performed using soap and water only every shift and as needed.
Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the
development of drug-resistant bacteria.
(Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is
not recommended for routine catheter care and infection prevention.
Educational objective:
Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene,
, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder
and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag,
and using sterile technique when collecting urine specimens.
4-A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the
emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines
in my top dresser drawer." Which is the best response by the nurse?
1. "Can you lock your dresser drawer?"
2. "Make sure all of your medicines have childproof
caps."
3. "That sounds like a safe plan."
4. "You need to keep an eye on your child at all times."
Explanation:
Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like
many over-the-counter cold products. They usually find medicines when exploring their environment
and "getting into everything" when no one is watching. Children may find medicine in a parent's coat
pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that
seems out of reach, children can climb on a chair or stool to reach it.
Medications are the leading cause of child poisoning. The best preventive measures include placing
all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting
them away after each use (Option 1).
(Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an
appropriate instruction; however, it is not the priority response in this situation.
(Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked.
(Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day,
toddlers need adult supervision when active and exploring their environment.
Educational objective:
The most important strategy to prevent accidental drug overdoses in children is teaching parents and
caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should
also be advised to put drugs away after each use.
5-The nurse recognizes that which factors place a client at increased risk for falls? Select all that
apply.
Age of 50
1.
Diagnosis of ovarian cancer
2.
Lying pulse 80/min, standing pulse 110/min
3.
Osteoarthritis of knees
