RNSG 1105 MIDTERM EXAM QUESTIONS AND
ANSWERS SET A+
✔✔When should the nurse perform hand hygiene? - ✔✔Before and after each patient
contact
✔✔When must the nurse wash hands rather than use an alcohol rub? - ✔✔at beginning
and end of shifts,
before and after wearing gloves for patient care or handling contaminated patient items.
✔✔8 Rights of Medication Administration - ✔✔1. Right Person
2. Right Medication
3. Right Time
4. Right Dose
5. Right Route
6. Right Position
7. Right Documentation
8. Right to Refuse
✔✔What is the purpose of patient records? - ✔✔Fosters communication and continuity
of care
✔✔communication - ✔✔interaction of people simultaneously sending & receiving
messages while interpreting perceptions & attitudes of the content followed by feedback
to correct or validate the communication.
Effective communication may be the single most important factor that determines the
success of the nurse's interventions with the patient and family.
✔✔What is a "Helping Relationship"? - ✔✔-Dynamic, purposeful, and time limited
-Person providing assistance is personally accountable for the outcomes.
-Patient-focused, defined in the terms of the patient's needs
-NOT trying to develop a friendship, it is a professional relationship
, ✔✔Can restraints be applied prior to obtaining an HCP order? - ✔✔Yes
✔✔Define safety - ✔✔Freedom from psychological and physical injury
✔✔Why is there a safety goal for falls? - ✔✔because falls resulting in patient injury are
a prevalent patient safety problem
✔✔Sentinel Event - ✔✔Unexpected adverse event "involving death or serious physical
or psychological injury, or the risk thereof"
✔✔What should you do if the patient complains of pain / discomfort from the restraint? -
✔✔Check restraint/ROM/CMS
✔✔With restraints, what can be delegated to NAP? - ✔✔-Can watch the patient
-Can apply the restraint
-Can do routine checks
✔✔What are patient ergonomics? - ✔✔having the right tool for the task
✔✔How often do you assess the restrained patient? - ✔✔Assess CMS q 15 min
(agency protocol) and hydration / toileting / signs sensory deprivation q 1 hour or less as
needed (PRN)
✔✔How often is the restraint removed and a less restrictive method tried? - ✔✔Every 2
hours
✔✔How long is a restraint order good for? - ✔✔4 hours
✔✔Where and how is a restraint tied? - ✔✔The restraint is tied to the bed frame (not at
a joint) and a quick release knot is used.
✔✔Guidelines for restraints - ✔✔Adults 18+ (8 hours max)
Children 9-17 (2 hours max
Children under age 9 (1 hour max)
-Evaluate ever 15 minutes!
-Remove restraints ever 2 hours
✔✔List interventions for patients at high risk for falls - ✔✔Bed alarms, chair alarms;
Visual alerts (yellow bracelets, door magnets, bed alarms, white boards)
Mechanical lift devices & other patient handling equipment
Instruct patient to ambulate with assistance only (Gait belts).
Hourly Rounding to Offer assistance with toileting.
Consider placing patient close to nurse's station.
ANSWERS SET A+
✔✔When should the nurse perform hand hygiene? - ✔✔Before and after each patient
contact
✔✔When must the nurse wash hands rather than use an alcohol rub? - ✔✔at beginning
and end of shifts,
before and after wearing gloves for patient care or handling contaminated patient items.
✔✔8 Rights of Medication Administration - ✔✔1. Right Person
2. Right Medication
3. Right Time
4. Right Dose
5. Right Route
6. Right Position
7. Right Documentation
8. Right to Refuse
✔✔What is the purpose of patient records? - ✔✔Fosters communication and continuity
of care
✔✔communication - ✔✔interaction of people simultaneously sending & receiving
messages while interpreting perceptions & attitudes of the content followed by feedback
to correct or validate the communication.
Effective communication may be the single most important factor that determines the
success of the nurse's interventions with the patient and family.
✔✔What is a "Helping Relationship"? - ✔✔-Dynamic, purposeful, and time limited
-Person providing assistance is personally accountable for the outcomes.
-Patient-focused, defined in the terms of the patient's needs
-NOT trying to develop a friendship, it is a professional relationship
, ✔✔Can restraints be applied prior to obtaining an HCP order? - ✔✔Yes
✔✔Define safety - ✔✔Freedom from psychological and physical injury
✔✔Why is there a safety goal for falls? - ✔✔because falls resulting in patient injury are
a prevalent patient safety problem
✔✔Sentinel Event - ✔✔Unexpected adverse event "involving death or serious physical
or psychological injury, or the risk thereof"
✔✔What should you do if the patient complains of pain / discomfort from the restraint? -
✔✔Check restraint/ROM/CMS
✔✔With restraints, what can be delegated to NAP? - ✔✔-Can watch the patient
-Can apply the restraint
-Can do routine checks
✔✔What are patient ergonomics? - ✔✔having the right tool for the task
✔✔How often do you assess the restrained patient? - ✔✔Assess CMS q 15 min
(agency protocol) and hydration / toileting / signs sensory deprivation q 1 hour or less as
needed (PRN)
✔✔How often is the restraint removed and a less restrictive method tried? - ✔✔Every 2
hours
✔✔How long is a restraint order good for? - ✔✔4 hours
✔✔Where and how is a restraint tied? - ✔✔The restraint is tied to the bed frame (not at
a joint) and a quick release knot is used.
✔✔Guidelines for restraints - ✔✔Adults 18+ (8 hours max)
Children 9-17 (2 hours max
Children under age 9 (1 hour max)
-Evaluate ever 15 minutes!
-Remove restraints ever 2 hours
✔✔List interventions for patients at high risk for falls - ✔✔Bed alarms, chair alarms;
Visual alerts (yellow bracelets, door magnets, bed alarms, white boards)
Mechanical lift devices & other patient handling equipment
Instruct patient to ambulate with assistance only (Gait belts).
Hourly Rounding to Offer assistance with toileting.
Consider placing patient close to nurse's station.
