2024 NURS 342 EXAM 4 WITH 100% CORRECT ANSWSERS
AND WELL COMPOSED QUESTIONS.
What is the purpose of a gait belt? - ANSWER It provides a means to steady a
patient at the center of gravity or to transfer a patient safely without pulling on the
patient's body.
A combative patient comes in to the emergency room and is swinging his fists at
the nurses. With the assistance of security, the charge nurse places wrist restraints
on the patient. What would be a priority action at this time? - ANSWER Notify the
health care provider for follow-up evaluation.
The patient begins to cough and choke while the nurse is feeding him. What should
the nurse do? - ANSWER Suction the airway as necessary.
The nurse checks the patient's extremity restraints hourly. What is the nurse looking
for related to this type of restraint? - ANSWER • Distal pulses.
• Temperature of the skin distal to the restraint.
• Proper placement of the restraint.
• Sensation of the distal part of the extremity.
• Color of skin distal to the restraint.
If a patient has dysphagia (difficulty swallowing), which foods found on the patient's
tray may be cause for concern or require further intervention? - ANSWER • Grape
juice
• Sausage patty
• Toast with butter
The nurse is caring for an elderly person who has suffered a stroke and now has
left side weakness and dysphagia. The nurse is being very careful to prevent the
patient from aspirating by taking which of the following measures? - ANSWER •
Having the patient maintain an upright position for 30 to 60 minutes after eating.
• Having the patient tilt her head forward slightly when swallowing.
Risk factors for falls among inpatients - ANSWER a history of falling
muscle weakness
agitation and confusion
urinary incontinence or frequency
postural hypotension
use of high risk medications (e.g., benzodiazepines, opioids and antihistamines, and
sedative hypnotics)
When should side rails be up? - ANSWER when patient is confused, sedated, or
weak
Physical restraint - ANSWER any manual method, physical or mechanical device,
material, or equipment that immobilizes or reduces the ability of a patient to move
their extremities, body, or head freely.
Restraint options - ANSWER Elbow Restraint
Belt restraint
Extremity (ankle or wrist) restraint
Mitten restraint
AND WELL COMPOSED QUESTIONS.
What is the purpose of a gait belt? - ANSWER It provides a means to steady a
patient at the center of gravity or to transfer a patient safely without pulling on the
patient's body.
A combative patient comes in to the emergency room and is swinging his fists at
the nurses. With the assistance of security, the charge nurse places wrist restraints
on the patient. What would be a priority action at this time? - ANSWER Notify the
health care provider for follow-up evaluation.
The patient begins to cough and choke while the nurse is feeding him. What should
the nurse do? - ANSWER Suction the airway as necessary.
The nurse checks the patient's extremity restraints hourly. What is the nurse looking
for related to this type of restraint? - ANSWER • Distal pulses.
• Temperature of the skin distal to the restraint.
• Proper placement of the restraint.
• Sensation of the distal part of the extremity.
• Color of skin distal to the restraint.
If a patient has dysphagia (difficulty swallowing), which foods found on the patient's
tray may be cause for concern or require further intervention? - ANSWER • Grape
juice
• Sausage patty
• Toast with butter
The nurse is caring for an elderly person who has suffered a stroke and now has
left side weakness and dysphagia. The nurse is being very careful to prevent the
patient from aspirating by taking which of the following measures? - ANSWER •
Having the patient maintain an upright position for 30 to 60 minutes after eating.
• Having the patient tilt her head forward slightly when swallowing.
Risk factors for falls among inpatients - ANSWER a history of falling
muscle weakness
agitation and confusion
urinary incontinence or frequency
postural hypotension
use of high risk medications (e.g., benzodiazepines, opioids and antihistamines, and
sedative hypnotics)
When should side rails be up? - ANSWER when patient is confused, sedated, or
weak
Physical restraint - ANSWER any manual method, physical or mechanical device,
material, or equipment that immobilizes or reduces the ability of a patient to move
their extremities, body, or head freely.
Restraint options - ANSWER Elbow Restraint
Belt restraint
Extremity (ankle or wrist) restraint
Mitten restraint
