2
NUR204 exam 2 with verified solutions and rationales || || || || || || ||
1. 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.
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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.||
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.
|| || || || || || || || || ||
2. 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
|| || || || ||
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. || ||
,2
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.
|| || || || || ||
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.
|| || || || || || ||
4. 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.
|| || || || || || || ||
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.
|| || || || || || || ||
5. 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.)
|| || || || || || || || || || || || ||
,2
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.
|| || || || || || || ||
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.
|| || || || ||
, 2
d. Place bedside table between patient and the bathroom to use as a resting area.
|| || || || || || || || || || || || || ||
e. Ensure that all patients have bedside commode access.
|| || || || || || || ||
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.
|| || || || || || || ||
7. 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."
|| || || || || || || || || || || || || ||
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. ||
8. A patient is being discharged and several previous medications are being discontinued.
|| || || || || || || || || || || || ||
The patient asks the nurse what she should do with unused medications. The nurse
|| || || || || || || || || || || || || ||
NUR204 exam 2 with verified solutions and rationales || || || || || || ||
1. 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.||
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.
|| || || || || || || || || ||
2. 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
|| || || || ||
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. || ||
,2
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.
|| || || || || ||
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.
|| || || || || || ||
4. 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.
|| || || || || || || ||
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.
|| || || || || || || ||
5. 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.)
|| || || || || || || || || || || || ||
,2
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.
|| || || || || || || ||
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.
|| || || || ||
, 2
d. Place bedside table between patient and the bathroom to use as a resting area.
|| || || || || || || || || || || || || ||
e. Ensure that all patients have bedside commode access.
|| || || || || || || ||
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.
|| || || || || || || ||
7. 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."
|| || || || || || || || || || || || || ||
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. ||
8. A patient is being discharged and several previous medications are being discontinued.
|| || || || || || || || || || || || ||
The patient asks the nurse what she should do with unused medications. The nurse
|| || || || || || || || || || || || || ||
