NURS 200 EXAM #1 QUESTIONS WITH
CORRECT ANSWERS
Identify patient's perception of safety needs and risks
Identify actual and potential threats to the patient's safety.
Determine impact of the underlying illness on the patient's safety.
Identify the presence of risks for the patient's developmental stage and patient's
environment.
Determine medication history and side effects posing safety risks. - ANSWER-What
is involved during the assessment of the nursing process?
Involve patient as a partner in planning care.
Select nursing interventions to promote safety according to the patient's
developmental and health care needs.
Consult with occupational and physical therapists for assistive devices and home
modifications of safety hazards.
Select interventions that will improve the safety of the patient's home environment. -
ANSWER-What is involved during the planning of the nursing process?
Interventions based on nursing diagnosis - ANSWER-What is involved during the
implementation of the nursing process.
Evaluate if patient's expectations of care are met.
Reassess the patient for the presence of physical, social, environmental or
developmental risks.
Determine if changes in the patient's care resulted in increased threats to safety. -
ANSWER-What is involved during the evaluation of the nursing process?
Age of 85
Bone disorders (osteoporosis, metastasis, i.e.)
Coagulation disorders (leukemia, i.e.)
Surgery (thoracic and abdominal surgery, i.e) - ANSWER-What is the mnemonic that
helps to determine whether a patient has a recent history of fall or risks for injury?
What does each letter stand for?
2, 4, 5 - ANSWER-Which of the following are safe practices to follow in the safe
preparation and storage of food? (Select all that apply.)
1. Always use a single cutting board to prepare foods for cooking.
2. Refrigerate leftovers as soon as possible.
3. Always buy vegetables in packages marked "prewashed."
4. Cook meats to the proper temperature.
5. Wash hands thoroughly before food preparation.
3, 4, 5 - ANSWER-A nurse enters the hospital room of a patient who had a total knee
replacement the day before. Which of the following pose potential safety risks?
(Select all that apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
,3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The overbed table with the patients glasses is positioned against the wall opposite
the end of the bed.
1, 3, 4 - ANSWER-A nurse working on a medicine unit in the hospital hears the fire
alarm go off. As the nurse walks down the hallway, there is smoke coming from the
family waiting area. Which of the following steps should the nurse take? (Select all
that apply.)
1. Immediately phone in to the hospital alert system the exact location of the fire.
2. Direct the nurse technician to place empty stretchers behind the fire doors.
3. Go to each patient room, and direct ambulatory patients to walk themselves to a
safe area.
4. Work with the nurse technician to help move patients requiring wheelchairs from
their rooms.
5. Close the room doors of patients who cannot get out of bed, and keep them in
their rooms.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: An older adult has limited finances.
Developmental risks - ANSWER-Categorize the threat to safety as individual risks or
developmental risks: A young toddler likes to explore objects by placing them in his
mouth.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A 55 year old patient has a residual gait change due to a
stroke.
Vital signs, skin integrity underneath the restraint, nutrition, hydration, circulation to
an extremity, range of motion, hygiene, elimination needs, cognitive functioning,
psychological status and need for restraint - ANSWER-What must be monitored on a
patient who has restraints?
Reduce risk of patient injury from falls.
Prevent interruption of therapy such as traction, IV infusions, nasogastric tube
feeding or Foley catheterization.
Prevent patients who are confused or combative from removing life support
equipment.
Reduce the risk of injury to other by the patient. - ANSWER-What are the following
objectives that must be met to require the use of restraints?
Assign confused or disoriented patients to rooms near nurses' station and observe
frequently. - ANSWER-What is an alternative to restraint for confused or disoriented
patients?
Use de-escalation, time out and other verbal intervention techniques when managing
aggressive behaviors. - ANSWER-What is an alternative to restraint for aggressive
behaviors?
,Camouflage intravenous lines with clothing, stockinette, or Kling gauze dressing. -
ANSWER-What is an alternative to restraint for patients who mess with their IV?
Yes, they are considered a restraint because they increase the risk of falls when
patients attempt to get out of bed or crawl over the rail. They can also lead to
patient's becoming caught, trapped, entangled or strangled especially in the frail,
elderly or confused patients. - ANSWER-Are side rails considered a restraint? If so,
why?
Assessment of patient's mobility and responsiveness to instructions. - ANSWER-
What determines if side rails are safe to be used on a patient?
R - Rescue and remove all patients in immediate danger
A - Activate the alarm.
C - Confine the fire by closing doors and windows and turning of oxygen and
electrical equipment
E - Extinguish the fire with an appropriate extinguisher - ANSWER-What mnemonic
helps set priorities during a fire? What does each letter stand for?
Seizure - ANSWER-Hyperexcitation and disorderly discharge of neurons in the brain,
leading to a sudden, violent, involuntary series of muscle contractions that is
episodic, causing loss of consciousness, falling, tonicity and clonicity.
tonicity - ANSWER-rigidity of muscles
clonicity - ANSWER-jerking of muscles
Aura - ANSWER-subjective sensation experience at the onset of a neurological
condition, often is a bright light, smell or taste.
Status epilepticus - ANSWER-A medical emergency that requires intensive
monitoring and treatment, caused when seizures are prolonged or repeated.
Position patient, making sure to protect the patients head.
Clear surrounding area of furniture and anything else that is hard or sharp.
If possible, turn patient onto one side, head tilted slightly forward.
Do not restrain patient, hold limbs loosely if they are flailing.
Loosing clothing and remove eyeglasses.
Do not put anything in the patients mouth and do not force apart a patient's clenched
teeth. - ANSWER-What are tips for protecting a patient during a seizure?
Developmental risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A school age child chooses to play ice hockey.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A patient newly diagnosed with diabetes has low health literacy.
4 - ANSWER-A nurse working on a surgery floor is assigned four patients. The nurse
assesses each patient, noting behaviors and physical signs and symptoms. Which of
the following patients is more likely to be violent toward the nurse?
, 1. The first patient maintains eye contact with the nurse, is calm during the nurse's
assessment, and asks questions frequently.
2. The second patient is very drowsy, loses attention span when the nurse asks
questions, and mumbles when speaking.
3. The third patient moves nervously in bed, swears and grimaces when trying to
cough, and speaks in a low volume.
4. The fourth patient speaks in a loud voice and becomes irritable when the nurse
arrives to help walk the patient.
2, 3, 5 - ANSWER-A nurse working the night shift is assigned a patient who has a
history of having fallen in the hospital during a previous admission. The nurse wants
to review the admission assessment completed by the nurse on the day shift. Which
of the following sections in the assessment are most likely to provide information
about the patient's current fall risks? (Select all that apply.)
1. Allergy history
2. Medication history
3. Patient age
4. Patient's occupation
5. Physical exam of neuromuscular function
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children proper bicycle and skate board safety.
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children how to cross streets and walk in parking lot.
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children proper techniques for specific sports.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to operate electric toothbrushes while unsupervised.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to talk to or go with a stranger.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to eat items found in the grass.
3, 4, 6 - ANSWER-The nurse finds a 68 year old woman wandering in the hallway
and exhibiting confusion. The patients says she is looking for the bathroom. Which
interventions are appropriate for this patient? (Select all that apply.)
1. Ask the health care provider to order a restraint
2. Recommend insertion of a urinary catheter
3. Provide scheduled toileting rounds every 2 to 3 hours
CORRECT ANSWERS
Identify patient's perception of safety needs and risks
Identify actual and potential threats to the patient's safety.
Determine impact of the underlying illness on the patient's safety.
Identify the presence of risks for the patient's developmental stage and patient's
environment.
Determine medication history and side effects posing safety risks. - ANSWER-What
is involved during the assessment of the nursing process?
Involve patient as a partner in planning care.
Select nursing interventions to promote safety according to the patient's
developmental and health care needs.
Consult with occupational and physical therapists for assistive devices and home
modifications of safety hazards.
Select interventions that will improve the safety of the patient's home environment. -
ANSWER-What is involved during the planning of the nursing process?
Interventions based on nursing diagnosis - ANSWER-What is involved during the
implementation of the nursing process.
Evaluate if patient's expectations of care are met.
Reassess the patient for the presence of physical, social, environmental or
developmental risks.
Determine if changes in the patient's care resulted in increased threats to safety. -
ANSWER-What is involved during the evaluation of the nursing process?
Age of 85
Bone disorders (osteoporosis, metastasis, i.e.)
Coagulation disorders (leukemia, i.e.)
Surgery (thoracic and abdominal surgery, i.e) - ANSWER-What is the mnemonic that
helps to determine whether a patient has a recent history of fall or risks for injury?
What does each letter stand for?
2, 4, 5 - ANSWER-Which of the following are safe practices to follow in the safe
preparation and storage of food? (Select all that apply.)
1. Always use a single cutting board to prepare foods for cooking.
2. Refrigerate leftovers as soon as possible.
3. Always buy vegetables in packages marked "prewashed."
4. Cook meats to the proper temperature.
5. Wash hands thoroughly before food preparation.
3, 4, 5 - ANSWER-A nurse enters the hospital room of a patient who had a total knee
replacement the day before. Which of the following pose potential safety risks?
(Select all that apply.)
1. A current safety inspection sticker is on the IV fluids pump.
2. A walker is positioned near the patient's bedside.
,3. The hospital bed is in the high position.
4. There is no gait belt at the bedside.
5. The overbed table with the patients glasses is positioned against the wall opposite
the end of the bed.
1, 3, 4 - ANSWER-A nurse working on a medicine unit in the hospital hears the fire
alarm go off. As the nurse walks down the hallway, there is smoke coming from the
family waiting area. Which of the following steps should the nurse take? (Select all
that apply.)
1. Immediately phone in to the hospital alert system the exact location of the fire.
2. Direct the nurse technician to place empty stretchers behind the fire doors.
3. Go to each patient room, and direct ambulatory patients to walk themselves to a
safe area.
4. Work with the nurse technician to help move patients requiring wheelchairs from
their rooms.
5. Close the room doors of patients who cannot get out of bed, and keep them in
their rooms.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: An older adult has limited finances.
Developmental risks - ANSWER-Categorize the threat to safety as individual risks or
developmental risks: A young toddler likes to explore objects by placing them in his
mouth.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A 55 year old patient has a residual gait change due to a
stroke.
Vital signs, skin integrity underneath the restraint, nutrition, hydration, circulation to
an extremity, range of motion, hygiene, elimination needs, cognitive functioning,
psychological status and need for restraint - ANSWER-What must be monitored on a
patient who has restraints?
Reduce risk of patient injury from falls.
Prevent interruption of therapy such as traction, IV infusions, nasogastric tube
feeding or Foley catheterization.
Prevent patients who are confused or combative from removing life support
equipment.
Reduce the risk of injury to other by the patient. - ANSWER-What are the following
objectives that must be met to require the use of restraints?
Assign confused or disoriented patients to rooms near nurses' station and observe
frequently. - ANSWER-What is an alternative to restraint for confused or disoriented
patients?
Use de-escalation, time out and other verbal intervention techniques when managing
aggressive behaviors. - ANSWER-What is an alternative to restraint for aggressive
behaviors?
,Camouflage intravenous lines with clothing, stockinette, or Kling gauze dressing. -
ANSWER-What is an alternative to restraint for patients who mess with their IV?
Yes, they are considered a restraint because they increase the risk of falls when
patients attempt to get out of bed or crawl over the rail. They can also lead to
patient's becoming caught, trapped, entangled or strangled especially in the frail,
elderly or confused patients. - ANSWER-Are side rails considered a restraint? If so,
why?
Assessment of patient's mobility and responsiveness to instructions. - ANSWER-
What determines if side rails are safe to be used on a patient?
R - Rescue and remove all patients in immediate danger
A - Activate the alarm.
C - Confine the fire by closing doors and windows and turning of oxygen and
electrical equipment
E - Extinguish the fire with an appropriate extinguisher - ANSWER-What mnemonic
helps set priorities during a fire? What does each letter stand for?
Seizure - ANSWER-Hyperexcitation and disorderly discharge of neurons in the brain,
leading to a sudden, violent, involuntary series of muscle contractions that is
episodic, causing loss of consciousness, falling, tonicity and clonicity.
tonicity - ANSWER-rigidity of muscles
clonicity - ANSWER-jerking of muscles
Aura - ANSWER-subjective sensation experience at the onset of a neurological
condition, often is a bright light, smell or taste.
Status epilepticus - ANSWER-A medical emergency that requires intensive
monitoring and treatment, caused when seizures are prolonged or repeated.
Position patient, making sure to protect the patients head.
Clear surrounding area of furniture and anything else that is hard or sharp.
If possible, turn patient onto one side, head tilted slightly forward.
Do not restrain patient, hold limbs loosely if they are flailing.
Loosing clothing and remove eyeglasses.
Do not put anything in the patients mouth and do not force apart a patient's clenched
teeth. - ANSWER-What are tips for protecting a patient during a seizure?
Developmental risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A school age child chooses to play ice hockey.
Individual risks - ANSWER-Categorize the threat to safety as individual risk or
developmental risks: A patient newly diagnosed with diabetes has low health literacy.
4 - ANSWER-A nurse working on a surgery floor is assigned four patients. The nurse
assesses each patient, noting behaviors and physical signs and symptoms. Which of
the following patients is more likely to be violent toward the nurse?
, 1. The first patient maintains eye contact with the nurse, is calm during the nurse's
assessment, and asks questions frequently.
2. The second patient is very drowsy, loses attention span when the nurse asks
questions, and mumbles when speaking.
3. The third patient moves nervously in bed, swears and grimaces when trying to
cough, and speaks in a low volume.
4. The fourth patient speaks in a loud voice and becomes irritable when the nurse
arrives to help walk the patient.
2, 3, 5 - ANSWER-A nurse working the night shift is assigned a patient who has a
history of having fallen in the hospital during a previous admission. The nurse wants
to review the admission assessment completed by the nurse on the day shift. Which
of the following sections in the assessment are most likely to provide information
about the patient's current fall risks? (Select all that apply.)
1. Allergy history
2. Medication history
3. Patient age
4. Patient's occupation
5. Physical exam of neuromuscular function
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children proper bicycle and skate board safety.
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children how to cross streets and walk in parking lot.
School-age child - ANSWER-Determine if the intervention for promoting child safety
is meant for the developmental stage school-age child or preschooler: Teach
children proper techniques for specific sports.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to operate electric toothbrushes while unsupervised.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to talk to or go with a stranger.
Preschooler - ANSWER-Determine if the intervention for promoting child safety is
meant for the developmental stage school-age child or preschooler: Teach children
not to eat items found in the grass.
3, 4, 6 - ANSWER-The nurse finds a 68 year old woman wandering in the hallway
and exhibiting confusion. The patients says she is looking for the bathroom. Which
interventions are appropriate for this patient? (Select all that apply.)
1. Ask the health care provider to order a restraint
2. Recommend insertion of a urinary catheter
3. Provide scheduled toileting rounds every 2 to 3 hours
