FUNDAMENTALS PATIENT SAFETY
(TEST BANK) EXAM QUESTIONS AND
ANSWERS
Most medication errors occur in the ordering and administering stages of the
medication process.
During the admission assessment, the nurse assesses the patient for fall risk. Which
of the following has the greatest potential to increase the patient's risk for falls?
a. The patient is 59 years of age.
b. The patient walks 2 miles a day.
c. The patient takes Benadryl (diphenhydramine) for allergies.
d. The patient recently became widowed. - Answer-ANS: C
Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as
a side effect, thereby increasing the risk for falls. Over 60 is the age typically found
on fall assessments that increase the risk for falls. Walking has many benefits,
including increasing strength, which would be beneficial in decreasing risk.
Becoming widowed would increase stress and may affect concentration but is not
the greatest risk.
The older patient presents to the emergency department after stepping in front of a
car at a crosswalk. After the patient has been triaged, the nurse interviews the
patient. Which of the following comments would require follow-up by the nurse?
a. "I try to exercise, so I walk that block almost every day."
b. "I waited and stepped out when the traffic sign said go."
c. "The car was going too fast, the speed limit is 20."
d. "I was so surprised; I didn't see or hear the car coming." - Answer-ANS: D
The patient did not see or hear the car coming. As patients age, sensory impairment
can increase the risk for injury. This statement by the patient would require follow-up
by the nurse. The patient needs hearing and eye examinations. Exercise is important
at every stage of development. The patient seemed to comprehend how to cross an
intersection correctly and was able to determine the speed of the car.
The patient presents to the clinic with a family member. The family member states
that the patient has been wandering around the house and mumbling. What is the
first assessment the nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment. - Answer- ANS: B
Introduce self and engage the patient by asking her name to assess orientation; ask
the patient why she is visiting the clinic today. Continue the assessment with vital
signs and a complete workup, including a neurologic assessment
The emergency department has been notified of a potential bioterrorist attack. The
nurse assigned to the department realizes that the most important task for safety in
this situation is to
a. Carry out the role and responsibilities of the nurse quickly and efficiently.
, b. Cluster all patients with the same symptoms to a specific part of the department.
c. Determine the biologic agent and manage all patients using Standard Precautions.
d. Prepare for post-traumatic stress associated with this bioterrorist attack. - Answer-
ANS: C
It is essential to determine the agent and manage all patients who are symptomatic
with the suspected or confirmed bioterrorism-related illness using Standard
Precautions. For certain diseases, additional precautions may be necessary.
Clustering patients may be helpful with staffing and, depending on the illness, may
decrease the spread. All nurses every day should carry out their roles quickly and
efficiently. Psychosocial concerns are important but are not the first priority at this
moment.
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
a. Risk for poisoning.
b. Knowledge deficit.
c. Impaired home maintenance.
d. Risk for injury. - Answer-ANS: D
The patient's behaviors support the nursing diagnosis of risk for injury. The patient is
confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury
could result if the patient falls out of bed or begins to bleed from a pulled line.
Nothing in the scenario indicates that this patient lacks knowledge or is at risk for
poisoning. Nothing in the scenario refers to the patient's home maintenance.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care. - Answer-ANS: A
The priority nursing diagnosis is risk for injury. This patient could cause harm to
himself by interrupting the oxygen therapy or by damaging the urethra by pulling the
urinary catheter out. Before restraining a patient, it is important to implement and
exhaust alternatives to restraint. Alternatives can include distraction and providing
companionship or supervision. Patients may be moved to a location closer to the
nurses' station; trained sitters or family members may be involved. Nurses need to
ensure that patients are provided adequate food, liquid, toileting, and relief from pain.
If these and other alternatives fail, this individual may need restraints; in this case, an
order would need to be obtained for the restraint. This patient may have deficient
knowledge; educating the patient about treatments could be considered as an
alternative to restraints; however, the nursing diagnosis of highest priority is risk for
injury. This scenario does not indicate that the patient has a disturbed body image or
that the patient's caregiver is strained.
The patient applies sequential compression devices after going to the bathroom. The
nurse checks the patient's application of the devices and finds that they have been
put on upside down. Which of the following nursing diagnoses will the nurse add to
the patient's plan of care?
(TEST BANK) EXAM QUESTIONS AND
ANSWERS
Most medication errors occur in the ordering and administering stages of the
medication process.
During the admission assessment, the nurse assesses the patient for fall risk. Which
of the following has the greatest potential to increase the patient's risk for falls?
a. The patient is 59 years of age.
b. The patient walks 2 miles a day.
c. The patient takes Benadryl (diphenhydramine) for allergies.
d. The patient recently became widowed. - Answer-ANS: C
Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as
a side effect, thereby increasing the risk for falls. Over 60 is the age typically found
on fall assessments that increase the risk for falls. Walking has many benefits,
including increasing strength, which would be beneficial in decreasing risk.
Becoming widowed would increase stress and may affect concentration but is not
the greatest risk.
The older patient presents to the emergency department after stepping in front of a
car at a crosswalk. After the patient has been triaged, the nurse interviews the
patient. Which of the following comments would require follow-up by the nurse?
a. "I try to exercise, so I walk that block almost every day."
b. "I waited and stepped out when the traffic sign said go."
c. "The car was going too fast, the speed limit is 20."
d. "I was so surprised; I didn't see or hear the car coming." - Answer-ANS: D
The patient did not see or hear the car coming. As patients age, sensory impairment
can increase the risk for injury. This statement by the patient would require follow-up
by the nurse. The patient needs hearing and eye examinations. Exercise is important
at every stage of development. The patient seemed to comprehend how to cross an
intersection correctly and was able to determine the speed of the car.
The patient presents to the clinic with a family member. The family member states
that the patient has been wandering around the house and mumbling. What is the
first assessment the nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment. - Answer- ANS: B
Introduce self and engage the patient by asking her name to assess orientation; ask
the patient why she is visiting the clinic today. Continue the assessment with vital
signs and a complete workup, including a neurologic assessment
The emergency department has been notified of a potential bioterrorist attack. The
nurse assigned to the department realizes that the most important task for safety in
this situation is to
a. Carry out the role and responsibilities of the nurse quickly and efficiently.
, b. Cluster all patients with the same symptoms to a specific part of the department.
c. Determine the biologic agent and manage all patients using Standard Precautions.
d. Prepare for post-traumatic stress associated with this bioterrorist attack. - Answer-
ANS: C
It is essential to determine the agent and manage all patients who are symptomatic
with the suspected or confirmed bioterrorism-related illness using Standard
Precautions. For certain diseases, additional precautions may be necessary.
Clustering patients may be helpful with staffing and, depending on the illness, may
decrease the spread. All nurses every day should carry out their roles quickly and
efficiently. Psychosocial concerns are important but are not the first priority at this
moment.
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
a. Risk for poisoning.
b. Knowledge deficit.
c. Impaired home maintenance.
d. Risk for injury. - Answer-ANS: D
The patient's behaviors support the nursing diagnosis of risk for injury. The patient is
confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury
could result if the patient falls out of bed or begins to bleed from a pulled line.
Nothing in the scenario indicates that this patient lacks knowledge or is at risk for
poisoning. Nothing in the scenario refers to the patient's home maintenance.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care. - Answer-ANS: A
The priority nursing diagnosis is risk for injury. This patient could cause harm to
himself by interrupting the oxygen therapy or by damaging the urethra by pulling the
urinary catheter out. Before restraining a patient, it is important to implement and
exhaust alternatives to restraint. Alternatives can include distraction and providing
companionship or supervision. Patients may be moved to a location closer to the
nurses' station; trained sitters or family members may be involved. Nurses need to
ensure that patients are provided adequate food, liquid, toileting, and relief from pain.
If these and other alternatives fail, this individual may need restraints; in this case, an
order would need to be obtained for the restraint. This patient may have deficient
knowledge; educating the patient about treatments could be considered as an
alternative to restraints; however, the nursing diagnosis of highest priority is risk for
injury. This scenario does not indicate that the patient has a disturbed body image or
that the patient's caregiver is strained.
The patient applies sequential compression devices after going to the bathroom. The
nurse checks the patient's application of the devices and finds that they have been
put on upside down. Which of the following nursing diagnoses will the nurse add to
the patient's plan of care?
