NUR204 EXAM 2 QUESTIONS WITH
ACCURATE SOLUTIONS
Which action should be taken when attempting to decrease falls in the
hospital setting?
a. Lower the height of the bed and the bottom two side rails before
leaving the room.
b. Ask patients on first encounter to use the bathroom and every 4
hours thereafter.
c. Instruct patients to use the call light only if they think they need help
getting out of bed.
d. Encourage patients to not take any prescribed medicine that could
cause drowsiness or light headedness. -- Correct Answer ✔✔ a
Keeping the bed in the lowest position and lowering the bottom side
rails decreases the chance of a fall. Hourly rounding for toileting is
recommended to improve patient safety. Patients should always use a
call light to get up even if they do not think they need it. Patients
should take prescribed medications but may need assistance with
ambulation.
The nurse demonstrates proper use of a fire extinguisher by taking
which action first?
a. Sweep from side to side
b. Pull the pin
,c. Squeeze the handles together
d. Aim and approach the fire -- Correct Answer ✔✔ b
The pin must be pulled to break the seal and activate the fire
extinguisher. When using a fire extinguisher, remembering the PASS
acronym (i.e., pull, aim, squeeze, and sweep) ensures proper
technique.
A nurse is assessing a patient in restraints. The nurse observes correct
use of restraints by checking which of the following?
a. Restraint is tied in a secure knot.
b. Restraint is secured to the bedrail.
c. Restraint allows for 3 to 4 fingers width between restraint and
patient's wrist.
d. Restraint is secured to the bedframe. -- Correct Answer ✔✔ d
Restraints should be secured to a part of the bed that moves with the
patient. The bedframe allows for a secure area to attach. The restraint
should always be tied in a quick release knot that can be easily untied
in an emergency. The recommendation is for two finger widths of
space between the restraint and the patient's extremity.
What actions should be taken when caring for an 80-year-old
postoperative patient with a history of Parkinson's disease?
a. Ensure that all four side rails are elevated.
b. Instruct family that they cannot leave the room.
c. Place wrists in soft restraints to protect invasive lines.
d. Include hourly rounding in the plan of care. -- Correct Answer ✔✔ d
,Hourly rounding prevents patient falls and addresses patient care
needs. Four side rails are considered a restraint. Restraints are used
only if other measures to keep the patient safe have been tried and
failed. It is the nurse's responsibility to care for the patient; families are
not required to be with patients at all times.
The nurse is caring for a patient requiring parenteral anticoagulant
therapy. Which of the following actions should the nurse take to
maximize patient safety? (Select all that apply.)
a. Double-check order and dosage with another RN.
b. Administer medication using a smart IV infusion pump.
c. Administer heparin only through a central venous catheter.
d. Monitor glucose every 6 hours.
e. Assess and document IV site every 8 hours. -- Correct Answer ✔✔ a,
b
Double-checking the order and dose with another RN can prevent
errors. Using an IV smart pump to administer anticoagulants increases
correct dose administration. Heparin can be administered through a
peripheral line. Glucose is not a focus of anticoagulant therapy. IV
access requires more frequent monitoring than every 8 hours.
. The nurse implements the necessary safety precautions in an
environment for a patient by doing which of the following? (Select all
that apply.)
a. Place bed in lowest position with brakes locked.
b. Put both upper side rails up while patients are in bed.
c. Move personal belongings within reach.
, d. Place bedside table between patient and the bathroom to use as a
resting area.
e. Ensure that all patients have bedside commode access. -- Correct
Answer ✔✔ a, b, c
The safest bed position is lowest to the ground and secure (brakes
intact) with the upper two side rails elevated. Raising all four side rails
is restrictive and should not be used. Having personal belongings
within reach minimizes patients moving about to get items. The
bedside table has wheels and is not stable to use for resting. It creates
an obstacle for the patient to navigate on the way to the bathroom and
would be better placed on the opposite side of the bed from the
bathroom. Some patients are able to walk to the bathroom; therefore,
they do not require a bedside commode.
The nurse would understand the need for further safety education
when a parent makes which of the following statements?
a. "I secure my 8-month-old in a rear-facing car seat in the back seat."
b. "My 10-year-old is angry that I still make him use a booster seat and
he is not permitted to ride in the front seat."
c. "My 2-month-old sleeps the longest when I put him in his crib on his
stomach."
d. "All of our household cleaners are stored in the upper cabinets in my
home." -- Correct Answer ✔✔ c
Infants should be placed on their backs to sleep to prevent sudden
infant death syndrome. The other statements all agree with safety
recommendations and show an understanding of correct behavior.
A patient is being discharged and several previous medications are
being discontinued. The patient asks the nurse what she should do
ACCURATE SOLUTIONS
Which action should be taken when attempting to decrease falls in the
hospital setting?
a. Lower the height of the bed and the bottom two side rails before
leaving the room.
b. Ask patients on first encounter to use the bathroom and every 4
hours thereafter.
c. Instruct patients to use the call light only if they think they need help
getting out of bed.
d. Encourage patients to not take any prescribed medicine that could
cause drowsiness or light headedness. -- Correct Answer ✔✔ a
Keeping the bed in the lowest position and lowering the bottom side
rails decreases the chance of a fall. Hourly rounding for toileting is
recommended to improve patient safety. Patients should always use a
call light to get up even if they do not think they need it. Patients
should take prescribed medications but may need assistance with
ambulation.
The nurse demonstrates proper use of a fire extinguisher by taking
which action first?
a. Sweep from side to side
b. Pull the pin
,c. Squeeze the handles together
d. Aim and approach the fire -- Correct Answer ✔✔ b
The pin must be pulled to break the seal and activate the fire
extinguisher. When using a fire extinguisher, remembering the PASS
acronym (i.e., pull, aim, squeeze, and sweep) ensures proper
technique.
A nurse is assessing a patient in restraints. The nurse observes correct
use of restraints by checking which of the following?
a. Restraint is tied in a secure knot.
b. Restraint is secured to the bedrail.
c. Restraint allows for 3 to 4 fingers width between restraint and
patient's wrist.
d. Restraint is secured to the bedframe. -- Correct Answer ✔✔ d
Restraints should be secured to a part of the bed that moves with the
patient. The bedframe allows for a secure area to attach. The restraint
should always be tied in a quick release knot that can be easily untied
in an emergency. The recommendation is for two finger widths of
space between the restraint and the patient's extremity.
What actions should be taken when caring for an 80-year-old
postoperative patient with a history of Parkinson's disease?
a. Ensure that all four side rails are elevated.
b. Instruct family that they cannot leave the room.
c. Place wrists in soft restraints to protect invasive lines.
d. Include hourly rounding in the plan of care. -- Correct Answer ✔✔ d
,Hourly rounding prevents patient falls and addresses patient care
needs. Four side rails are considered a restraint. Restraints are used
only if other measures to keep the patient safe have been tried and
failed. It is the nurse's responsibility to care for the patient; families are
not required to be with patients at all times.
The nurse is caring for a patient requiring parenteral anticoagulant
therapy. Which of the following actions should the nurse take to
maximize patient safety? (Select all that apply.)
a. Double-check order and dosage with another RN.
b. Administer medication using a smart IV infusion pump.
c. Administer heparin only through a central venous catheter.
d. Monitor glucose every 6 hours.
e. Assess and document IV site every 8 hours. -- Correct Answer ✔✔ a,
b
Double-checking the order and dose with another RN can prevent
errors. Using an IV smart pump to administer anticoagulants increases
correct dose administration. Heparin can be administered through a
peripheral line. Glucose is not a focus of anticoagulant therapy. IV
access requires more frequent monitoring than every 8 hours.
. The nurse implements the necessary safety precautions in an
environment for a patient by doing which of the following? (Select all
that apply.)
a. Place bed in lowest position with brakes locked.
b. Put both upper side rails up while patients are in bed.
c. Move personal belongings within reach.
, d. Place bedside table between patient and the bathroom to use as a
resting area.
e. Ensure that all patients have bedside commode access. -- Correct
Answer ✔✔ a, b, c
The safest bed position is lowest to the ground and secure (brakes
intact) with the upper two side rails elevated. Raising all four side rails
is restrictive and should not be used. Having personal belongings
within reach minimizes patients moving about to get items. The
bedside table has wheels and is not stable to use for resting. It creates
an obstacle for the patient to navigate on the way to the bathroom and
would be better placed on the opposite side of the bed from the
bathroom. Some patients are able to walk to the bathroom; therefore,
they do not require a bedside commode.
The nurse would understand the need for further safety education
when a parent makes which of the following statements?
a. "I secure my 8-month-old in a rear-facing car seat in the back seat."
b. "My 10-year-old is angry that I still make him use a booster seat and
he is not permitted to ride in the front seat."
c. "My 2-month-old sleeps the longest when I put him in his crib on his
stomach."
d. "All of our household cleaners are stored in the upper cabinets in my
home." -- Correct Answer ✔✔ c
Infants should be placed on their backs to sleep to prevent sudden
infant death syndrome. The other statements all agree with safety
recommendations and show an understanding of correct behavior.
A patient is being discharged and several previous medications are
being discontinued. The patient asks the nurse what she should do
