1 PRACTICE QUESTIONS WITH VERIFIED
ANSWERS LATEST UPDATE EXAM GUIDE
QUESTIONS MODIFIED TESTED AND
APPROVED
Contributing factors Fall -correct answer -->>Older age
Impaired mobility
Cognitive and/or Sensory impairment
Bowel and bladder dysfuntion
Side effects of medications
History of falls
Nursing interventions Falls -correct answer -->>Complete a fall risk
assessment
Communicate identified risks with the health care team
Assign clients at risk falls to a room close to nurses' stations and assess
frequently
Provide clients with nonskid footwear
Keep the floor free of clutter and maintain an unobstructed path to the
bathroom
Orient the client setting (grab bars, call light), including how to use and
locate all necessary items
Maintain bed in low position
Instruct the client who is unsteady to use the call light for assistance before
ambulating
Answer call lights promptly to prevent clients who are at risk from trying to
ambulate independently
Provide adequate lighting (nightlight for necessary trips to the bathroom)
Determine the client's ability to use assistive devices (walkers, canes, etc.).
Keep all items within reach
Use chair or bed sensors for client who are at risk
Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during
transfers or stops
Report and document all incidents per the facility policy
,Nursing intervention Restraints -correct answer -->>Implement
nonpharmacologic measures such as distraction, frequent observation, or
diversion activities
Prior to application, review manufacturer's instructions for correct
application
Notify the provider immediately when restraints are implemented
Remove the restraints and assess client every 2 hr
Assess neurovascular and neurosensory status every 2 hr
Leave the restraint loose enough to prevent injury
Always tie the restraint to the bed frame (using loose knots that are easily
removed)
Reassess the need for continue use
Document
Document Restraints -correct answer -->>Behaviors making restraint
necessary
Alternatives attempted and the client's response
Type and location of restraint and time applied
Frequency and type of assessment
Restraints should NEVER -correct answer -->>Interfere with treatment
Be used because of short-staffing or staff convenience
Not written as PRN orders
Nursing intervention Seizure precaution -correct answer -->>Assess
seizure history, noting frequency, presence of auras, and sequence of
events
Identify precipitating factors that may exacerbate or lead to seizure
Review medication history.
If routine lab work is required (Dilantin), when was last level drawn
Place rescue equipment at the bedside, including oxygen, oral airway, and
suction equipment
Establish IV or saline lock access for high risk clients
Inspects the client's environment for items that may cause injury in the
event of a seizure.
Remove any unnecessary items from the immediate environment
At the onset seizure, position the client for safety, and remain with client
If sitting or standing, ease client to floor. Protect the client's head. If client is
in bed, raise the side rails and pad for safety
,Roll the client to the side with the head flexed slightly forward
Do not put anything in the client's mouth
Loosen restrictive clothing
Accurately document the event, including timing precipitating behaviors or
events, and a description of the event (movements, loss of consciousness,
loss of continence, injuries, mention of aura, postictal state).
Report seizure to the provider
Fire response -correct answer -->>R-Rescue: protect and evacuate
clients in immediate danger
A-Alarm: Activate the alarm and report the fire
C-Contain: Close doors or windows
E-Extinguish: use correct fire extinguisher to exliminate the fire
"RACE"
Type fire extinguisher -correct answer -->>Class A
Class B
Class C
Class A -correct answer -->>Paper
Wood
Cloth
Trash
Class B -correct answer -->>Flammable liquids
Gases
Class C -correct answer -->>Electrical fires
Extinguish properly -correct answer -->>"PASS"
P-Pull
A-Aim
S-Squeeze
S-Sweep
Home Health setting -correct answer -->>Post "No Smoking" signs
Assess for risk (oxygen therapy, smoking, electrical equipment)
, Teach client to develop a plan of action in the event of a fire, including a
route of exit and a location where family members will meet
Instruct client to keep fire extinguisher accessible
Review "Stop, Drop, and Roll"
Nursing interventions on Equipment -correct answer -->>Electrial
equipment must be grounded
Do not overcrowd outlets
Do not extension cords on client care areas
Only used equipment for intended purpose
Regularly inspect equipment for frayed cords
Disconnect all equipment prior to cleaning
Nursing interventions on chemical and Radiation -correct answer --
>>Determine type and amount of radiation used
Place a sign on door. "Caution Radioactive Material."
Wear monitoring badge to record amount of exposure
Dispose of items removed from the room in appropriate containers
Never handle any type of radioactive agent with bare hands
Nursing interventions on lifting and transfer of clients -correct answer --
>>Assess mobility and strength
Instruct client to assist when possible
Use mechanical lift and assistive devices
Avoid twisting the thoracic spine or bending at the waist
Use major muscle groups, and tighten abdominal muscles
Nursing intervention on transferring clients from bed to chair or chair to bed
-correct answer -->>Instruct the client how to assist when possible
Lower the bed to the lowest setting
Position the bed or chair so that the client is moving toward the strong side
Assist the client to stand, then pivot
Nursing interventions repositioning clients in bed -correct answer --
>>Raise the bed to waist level
Lower side rails
Use slide boards or draw sheets
Have the client fold his arms across his chest while lifting the head