Answers
What is an appropriately worded goal for a patient who is at risk for falling? "The patient will be:
A. Taught how to call for help to ambulate."
B. Kept on bed rest when dizzy."
C. Restrained when agitated."
D. Free from trauma." Correct answer-D. Free from trauma."
This is an appropriate goal. It is realistic, specific, and measurable and has a time frame. It is realistic
to expect that all patients be safe. It is specific and measurable because safety from trauma can be
compared with standards of care within the profession of nursing. It has a time frame because the
words free from reflect the time frames of always, constantly, and continuously
A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged
plug. What rationale should the nurse provide when explaining why an electrical device must have a
three-pronged plug?
A. Controls stray electrical currents
B. Promotes efficient use of electricity
C. Shuts off the appliance if there is an electrical surge
D. Divides the electricity among the appliances in the room Correct answer-A. Controls stray
electrical currents
A three-pronged plug functions as a ground to dissipate stray electrical currents
A nurse is caring for a patient with Parkinson's disease who is experiencing difficulty swallowing.
What potential problem associated with dysphagia has the greatest influence on the plan of care?
A. Anorexia
B. Aspiration
C. Self-care deficit
D. Inadequate intake Correct answer-B. Aspiration
When a person has difficulty with swallowing (dysphagia), food or fluid can pass into the trachea and
be inhaled into the lungs (aspiration) rather than swallowed down the esophagus. This can result in
choking, partial or total airway obstruction, or aspiration pneumonia
The nurse is caring for a confused patient. What should the nurse do to prevent this patient from
falling?
A. Encourage the patient to use the corridor handrails
B. Place the patient in a room near the nurses' station
C. Reinforce how to use the call bell
D. Maintain close supervision Correct answer-D. Maintain close supervision
Maintaining safety of the confused patient is best accomplished through close or direct supervision.
Confused patients cannot be left on their own because they may not have the cognitive ability to
understand cause and effect, and therefore their actions can result in harm
A school nurse is teaching children about fire safety procedures. What is the first thing they should
be taught to do if their clothes catch on fire?
A. Yell for help
, B. Roll on the ground
C. Take their clothes off
D. Pour water on their clothes Correct answer-B. Roll on the ground
Rolling on the ground will smother the flames and put the fire out. Children should be taught to:
"stop, drop, and roll."
The practitioner orders a vest restraint for a patient. What should the nurse do first when applying
this restraint?
A. Perform an inspection of the patient's skin where the restraint is to be placed
B. Ensure the back of the vest is positioned on the patient's back
C. Permit four fingers to slide between the patient and the restraint
D. Secure the restraint to the bed frame using a slipknot Correct answer-A. Perform an inspection
of the patient's skin where the restraint is to be placed
Even when applied correctly, restraints can cause pressure and friction. A baseline assessment of the
skin under the restraint should be made. In addition, the presence of a dressing, pacemaker, or
subclavian catheter may influence the type of restraint to use
An unconscious patient begins vomiting. In which position should the nurse place the patient?
A. Supine
B. Side-lying
C. Orthopneic
D. Low fowler Correct answer-B. Side-lying
The side-lying position prevents the tongue from falling to the back of the oropharynx, allowing the
vomitus to flow out of the mouth by gravity and thus preventing aspiration
The nurse is assisting a patient to use a bedpan. What is the most important nursing intervention?
A. Dusting powder on the rim before placing the bedpan under the patient.
B. Positioning the rounded rim of the bedpan toward the front of the patient
C. Ensuring that the bedside rails are raised once the patient is on the bedpan
D. Encouraging the patient to help as much as possible when using the bedpan Correct answer-C.
Ensuring that the bedside rails are raised once the patient is on the bedpan
Patient safety is a priority. A bed pan is not a stable base of support and the effort of elimination may
require movements that alter balance. Side rails provide a solid object to hold while balancing on the
bedpan and supply a barrier to prevent falling out of bed.
A toaster is on fire in the pantry of a hospital unit. What should the nurse do first?
A. Unplug the toaster
B. Activate the fire alarm
C. Put out the fire with an extinguisher
D. Evacuate the patients from the room next to the kitchen Correct answer-B. Activate the fire
alarm
Because no patient is in jeopardy, the nurse's initial action should be to activate the alarm. The
sooner the alarm is set, the sooner professional firefighters will reach the scene of the fire
The risk management coordinator is preparing a program on the factors that contribute to falls in a
hospital setting. Which factor that most often contributes to falls should be included in the program?