NURS 3330: Foundations Exam #1 With
Complete Solutions
The Joint Commission is conducting an inspection. One of the inspectors asks the nurse
(you), "What is the first thing you would do if there is a fire in a patient's room?" The best
way for the nurse to respond is:
a. "I would find the nearest fire alarm."
b. "I would use the PASS method with the fire extinguisher."
c. "I would close the patient's door and evacuate other patients."
d. "I would assist the patient out of the room." - ANSWER d. "I would assist the patient
out of the room."
When admitting an older adult patient, the nurse's first action related to fall risks should
be:
a. Applying a "Fall Risk" bracelet to the patient's wrist
b. Performing a fall risk assessment
c. Ensuring that all four side rails on the bed are raised
d. Making sure the patient can reach their water pitcher - ANSWER b. Performing a fall
risk assessment
For a non-violent patient with wrist restraints, the nurse should perform assessment of
vital signs, skin, hygiene needs, and hydration:
a. At least every 15 minutes
b. At least daily
c. At least every 2 hours
d. Exactly every hour - ANSWER c. At least every 2 hours
A patient who has been recently diagnosed with an HIV infection should have
,a. An enteric precautions sign on their door
b. No sign on their door - standard precautions apply
c. A droplet precautions sign on their door
d. An airborne precautions sign on their door - ANSWER b. No sign on their door -
standard precautions apply
Identify the 2020/2021 National Patient Safety Goals (TJC website) - ANSWER 1. Identify
patients correctly (2 identifiers)
2. staff communication (Use standardized communication tools: SBAR: situation
background assessment recommendation- lab/test results e.g.)
3. Prevent mistakes in surgery ( surgeries on wrong sites, wrong patient, wrong
procedure)
4. use medications safely (allergies)
5. use alarms safely
6. prevent infection
Describe the areas of risk within a health care setting. - ANSWER fire risks:
- electrical issues
- equipment
- smoking
-sentinel events
-near miss events
-seizures
-restraints
-patient-inherited
-related accidents
- procedure related
- equipment related
,Fire Safety - ANSWER hospital staff must know location of exits, alarms, fire
extinguishers, oxygen shut-off valves
do not block doors with equipment
know evacuation plan
What does the acronym RACE stand for? - ANSWER rescue, alarm, contain, extinguish
What does the acronym PASS stand for? - ANSWER pull pin, aim at base of fire , squeeze
handle, sweep from side-to-side
Seizure - ANSWER a sudden surge of electrical activity in the brain due to epilepsy,
fever, or other medical condition.
What are some seizure precautions? - ANSWER - ensure that emergency equipment is
at bedside: oxygen, equipment, oral airway, suction equipment
- pad side rails
What are some nursing interventions for seizures? - ANSWER -ease patient to floor and
turn patient to side
- clear are of sharp objects
- protect head
-loosen anything around neck
- remove glasses
-time seizure
, What NOT to do when a patient is having a seizure? - ANSWER - hold person down
- place anything in mouth
- attempt mouth to mouth resuscitation
- offer water/food
The nurse is caring for a patient who is having a seizure. Which of the following
measures will protect the patient and the nurse from injury? (select all that apply)
a. If patient is standing, attempt to get him or her back in bed
b. With patient on floor, clear surrounding area of furniture or equipment
c. If possible, keep patient lying supine
d. Do not restrain patient; hold limbs loosely if they are flailing
e. Never force apart a patient's clenched teeth - ANSWER b, d, e
A nurse is evaluating a patient who is in soft restraints. Which of the following activities
does the nurse perform? SATA
a. Check patient's peripheral pulse in the restrained extremity
b. Evaluate patient's need for toileting
c. Offer the patient fluids if appropriate
d. Release both limbs at the same time to perform range of motion
e. Inspect the skin under each restraint - ANSWER b, c, e
A restraint must come from a provider? TRUE OR FALSE - ANSWER TRUE: Must have a
provider's order for use of restrains. In an emergency, nurse can apply restraints and
get order from provider within 1 hour.
Physical restraints include: - ANSWER - limb restraints
- vests
- belts
- having all 4 side rails. (may be appropriate for patients who are sedated or
Complete Solutions
The Joint Commission is conducting an inspection. One of the inspectors asks the nurse
(you), "What is the first thing you would do if there is a fire in a patient's room?" The best
way for the nurse to respond is:
a. "I would find the nearest fire alarm."
b. "I would use the PASS method with the fire extinguisher."
c. "I would close the patient's door and evacuate other patients."
d. "I would assist the patient out of the room." - ANSWER d. "I would assist the patient
out of the room."
When admitting an older adult patient, the nurse's first action related to fall risks should
be:
a. Applying a "Fall Risk" bracelet to the patient's wrist
b. Performing a fall risk assessment
c. Ensuring that all four side rails on the bed are raised
d. Making sure the patient can reach their water pitcher - ANSWER b. Performing a fall
risk assessment
For a non-violent patient with wrist restraints, the nurse should perform assessment of
vital signs, skin, hygiene needs, and hydration:
a. At least every 15 minutes
b. At least daily
c. At least every 2 hours
d. Exactly every hour - ANSWER c. At least every 2 hours
A patient who has been recently diagnosed with an HIV infection should have
,a. An enteric precautions sign on their door
b. No sign on their door - standard precautions apply
c. A droplet precautions sign on their door
d. An airborne precautions sign on their door - ANSWER b. No sign on their door -
standard precautions apply
Identify the 2020/2021 National Patient Safety Goals (TJC website) - ANSWER 1. Identify
patients correctly (2 identifiers)
2. staff communication (Use standardized communication tools: SBAR: situation
background assessment recommendation- lab/test results e.g.)
3. Prevent mistakes in surgery ( surgeries on wrong sites, wrong patient, wrong
procedure)
4. use medications safely (allergies)
5. use alarms safely
6. prevent infection
Describe the areas of risk within a health care setting. - ANSWER fire risks:
- electrical issues
- equipment
- smoking
-sentinel events
-near miss events
-seizures
-restraints
-patient-inherited
-related accidents
- procedure related
- equipment related
,Fire Safety - ANSWER hospital staff must know location of exits, alarms, fire
extinguishers, oxygen shut-off valves
do not block doors with equipment
know evacuation plan
What does the acronym RACE stand for? - ANSWER rescue, alarm, contain, extinguish
What does the acronym PASS stand for? - ANSWER pull pin, aim at base of fire , squeeze
handle, sweep from side-to-side
Seizure - ANSWER a sudden surge of electrical activity in the brain due to epilepsy,
fever, or other medical condition.
What are some seizure precautions? - ANSWER - ensure that emergency equipment is
at bedside: oxygen, equipment, oral airway, suction equipment
- pad side rails
What are some nursing interventions for seizures? - ANSWER -ease patient to floor and
turn patient to side
- clear are of sharp objects
- protect head
-loosen anything around neck
- remove glasses
-time seizure
, What NOT to do when a patient is having a seizure? - ANSWER - hold person down
- place anything in mouth
- attempt mouth to mouth resuscitation
- offer water/food
The nurse is caring for a patient who is having a seizure. Which of the following
measures will protect the patient and the nurse from injury? (select all that apply)
a. If patient is standing, attempt to get him or her back in bed
b. With patient on floor, clear surrounding area of furniture or equipment
c. If possible, keep patient lying supine
d. Do not restrain patient; hold limbs loosely if they are flailing
e. Never force apart a patient's clenched teeth - ANSWER b, d, e
A nurse is evaluating a patient who is in soft restraints. Which of the following activities
does the nurse perform? SATA
a. Check patient's peripheral pulse in the restrained extremity
b. Evaluate patient's need for toileting
c. Offer the patient fluids if appropriate
d. Release both limbs at the same time to perform range of motion
e. Inspect the skin under each restraint - ANSWER b, c, e
A restraint must come from a provider? TRUE OR FALSE - ANSWER TRUE: Must have a
provider's order for use of restrains. In an emergency, nurse can apply restraints and
get order from provider within 1 hour.
Physical restraints include: - ANSWER - limb restraints
- vests
- belts
- having all 4 side rails. (may be appropriate for patients who are sedated or
