NUR 204 EXAM 1: CRAVEN
QUESTIONS WITH RATIONAL
SOLUTIONS RATED A+
17. Fall prevention is done on multiple levels by nurses in the hospital. Which of the
following would not be an example of fall prevention done by nursing?
a. Reminding the patient to use the call light for assistance when getting out of bed
b. Placing the bed mattress on the floor to prevent injury
c. Developing an organizational policy for hourly rounding schedules to be performed on
each unit to monitor patient needs and comfort level
d. Applying restraints to patients at risk for falls - ANSWER-ANSWER: D
RATIONALE: Restraint application is not an appropriate method for reducing fall risk
and may cause more injury to the patient. Injury control interventions are centered at
three primary levels: the individual level (e.g., providing education about safety hazards
and prevention strategies); the design phase, using engineering and environmental
controls (active or passive safety features that can prevent injury from product or
equipment use); and the regulatory level, creating, monitoring, and enforcing regulations
to ensure safe products and environments. Reminding the patient to use the call light
would be individual education, placing the mattress on the floor would be environmental
or design prevention, and developing an organizational policy for monitoring would be at
the regulatory level of injury prevention.
17. Older adults may be at increased risk of injury related to physiologic factors. Which
of the following are relevant risk factors unique to this population? SATA
a. Decrease in sensory-perceptual function and cognitive judgment
b. Alcohol impairment
,c. Impaired thermoregulation
d. Medication side effects
e. Development of osteoporosis - ANSWER-ANSWER: A,C, D
RATIONALE: Advancing age entails loss in physical function and usually in acuity of
sensory-perceptual function (e.g., impaired vision). Older adults may have impaired
eyesight and hearing and decreased proprioception to maintain balance and sensitivity
to touch. The ability to thermoregulate may become impaired; older adults are at higher
risk than younger adults for hypothermia and heat stroke. Reflex responses slow, and
the musculoskeletal system can lose flexibility and strength. Various conditions, such as
osteoporosis, arthritis, or heart failure, can limit the ability to endure sustained physical
activity. Medications taken to control conditions such as high blood pressure or
Parkinson disease may result in orthostatic hypotension and increase the potential for
falling. Alcohol impairment is not unique to older adults.
17.The caregiver of a child asks about car safety for a 1-year-old child. What principle
will guide your answer?
a. Keep children facing the rear of the vehicle for as long as possible.
b. Children should be taken out of car seats as soon as possible.
c. The safest place for a child is in the front seat of the vehicle.
d. Children should use adult seat belts as soon as possible. - ANSWER-ANSWER: A
RATIONALE: Children should be kept rear-facing in the vehicle as long as possible. The
back seat of the car is the safest place for children. Children should be kept in car seats
or booster seats as long as possible, within the weight and height limits of the seat.
Adult seat belts should only be used when the child outgrows the car or booster seat.
17. Nurses should be aware of various safety hazards in the workplace. Which of the
following present safety hazards to nurses? SATA
,a. Cleaning solution spill
b. Chemotherapy administration
c. Needlestick injury
d. Assisting with patient mobility or transfers
e. Patient call systems - ANSWER-ANSWER: A, B, C, D
RATIONALE: These safety hazards are relevant to nursing work environments. Other
occupational hazards may include noise, hazardous dusts (e.g., asbestos, lead, coal)
and chemicals, heights, dangerous machines, biologically infectious agents, and
violence. Other dangers result when employers or workers do not follow safety
precautions, such as wearing protective gear and following safe work practices. Patient
call systems do not pose a risk to staff; in fact, they may alert staff to urgent needs that
create safety hazards for patients.
17. An error occurs as the result of the lack of a double-check process on dosing of a
high-risk opiate pain medication. The patient becomes oversedated, necessitating
reversal of the opioids in order to regain a regular respiratory pattern. Which of the
following should the nurse do to document the incident? SATA
a. Describe factors that led up to the incident
b. Document patient assessment findings following the error
c. Chart in the patient's record the contributing factors
d. Include interventions needed to reverse oversedation in incident report
e. Document your personal dissatisfaction with the response from pharmacy about the
incident - ANSWER-ANSWER: A, B, D
RATIONALE: Documentation of an error in an incident report should completely
describe all aspects of the event that occurred. Specifically, the report should include
the accident, patient assessment, and interventions provided for the patient. The report
is used for internal review to improve the system to prevent similar errors and cannot be
subpoenaed by a court of law. This document remains confidential and is not part of the
, patient's medical record; thus, the incident should not be detailed in the nursing notes or
other areas of the patient chart. Although professional judgment about things such as
contributing factors should be included, personal opinions about the situation should
not.
17. A nurse is providing discharge education for a postoperative patient who will be
leaving the hospital with a urinary catheter. What statement reflects appropriate
environmental safety education for this patient?
a. "Be aware that you are at risk for falling because the catheter tubing hangs by your
feet and is a tripping hazard."
b. "Your pain medications may cause side effects including drowsiness, so be sure not
to drive while you are taking them."
c. "Because of your incisions, you should be careful to not lift anything heavier than 10
lb."
d. "Change positions slowly to avoid dizziness." - ANSWER-ANSWER: A
RATIONALE: Environmental safety hazards include patient care devices such as
catheters, surgical drains, or sequential compression devices. All other statements are
appropriate surgical discharge education but are not related to environmental safety.
17. A nurse is assessing a patient for safety upon discharge following a severe stroke.
Which of the following systems would be a priority for this patient's safety? SATA
a. Neurologic system
b. Cardiovascular system
c. Skin integrity
d. Musculoskeletal system
e. Respiratory system - ANSWER-ANSWER: A, D, E
QUESTIONS WITH RATIONAL
SOLUTIONS RATED A+
17. Fall prevention is done on multiple levels by nurses in the hospital. Which of the
following would not be an example of fall prevention done by nursing?
a. Reminding the patient to use the call light for assistance when getting out of bed
b. Placing the bed mattress on the floor to prevent injury
c. Developing an organizational policy for hourly rounding schedules to be performed on
each unit to monitor patient needs and comfort level
d. Applying restraints to patients at risk for falls - ANSWER-ANSWER: D
RATIONALE: Restraint application is not an appropriate method for reducing fall risk
and may cause more injury to the patient. Injury control interventions are centered at
three primary levels: the individual level (e.g., providing education about safety hazards
and prevention strategies); the design phase, using engineering and environmental
controls (active or passive safety features that can prevent injury from product or
equipment use); and the regulatory level, creating, monitoring, and enforcing regulations
to ensure safe products and environments. Reminding the patient to use the call light
would be individual education, placing the mattress on the floor would be environmental
or design prevention, and developing an organizational policy for monitoring would be at
the regulatory level of injury prevention.
17. Older adults may be at increased risk of injury related to physiologic factors. Which
of the following are relevant risk factors unique to this population? SATA
a. Decrease in sensory-perceptual function and cognitive judgment
b. Alcohol impairment
,c. Impaired thermoregulation
d. Medication side effects
e. Development of osteoporosis - ANSWER-ANSWER: A,C, D
RATIONALE: Advancing age entails loss in physical function and usually in acuity of
sensory-perceptual function (e.g., impaired vision). Older adults may have impaired
eyesight and hearing and decreased proprioception to maintain balance and sensitivity
to touch. The ability to thermoregulate may become impaired; older adults are at higher
risk than younger adults for hypothermia and heat stroke. Reflex responses slow, and
the musculoskeletal system can lose flexibility and strength. Various conditions, such as
osteoporosis, arthritis, or heart failure, can limit the ability to endure sustained physical
activity. Medications taken to control conditions such as high blood pressure or
Parkinson disease may result in orthostatic hypotension and increase the potential for
falling. Alcohol impairment is not unique to older adults.
17.The caregiver of a child asks about car safety for a 1-year-old child. What principle
will guide your answer?
a. Keep children facing the rear of the vehicle for as long as possible.
b. Children should be taken out of car seats as soon as possible.
c. The safest place for a child is in the front seat of the vehicle.
d. Children should use adult seat belts as soon as possible. - ANSWER-ANSWER: A
RATIONALE: Children should be kept rear-facing in the vehicle as long as possible. The
back seat of the car is the safest place for children. Children should be kept in car seats
or booster seats as long as possible, within the weight and height limits of the seat.
Adult seat belts should only be used when the child outgrows the car or booster seat.
17. Nurses should be aware of various safety hazards in the workplace. Which of the
following present safety hazards to nurses? SATA
,a. Cleaning solution spill
b. Chemotherapy administration
c. Needlestick injury
d. Assisting with patient mobility or transfers
e. Patient call systems - ANSWER-ANSWER: A, B, C, D
RATIONALE: These safety hazards are relevant to nursing work environments. Other
occupational hazards may include noise, hazardous dusts (e.g., asbestos, lead, coal)
and chemicals, heights, dangerous machines, biologically infectious agents, and
violence. Other dangers result when employers or workers do not follow safety
precautions, such as wearing protective gear and following safe work practices. Patient
call systems do not pose a risk to staff; in fact, they may alert staff to urgent needs that
create safety hazards for patients.
17. An error occurs as the result of the lack of a double-check process on dosing of a
high-risk opiate pain medication. The patient becomes oversedated, necessitating
reversal of the opioids in order to regain a regular respiratory pattern. Which of the
following should the nurse do to document the incident? SATA
a. Describe factors that led up to the incident
b. Document patient assessment findings following the error
c. Chart in the patient's record the contributing factors
d. Include interventions needed to reverse oversedation in incident report
e. Document your personal dissatisfaction with the response from pharmacy about the
incident - ANSWER-ANSWER: A, B, D
RATIONALE: Documentation of an error in an incident report should completely
describe all aspects of the event that occurred. Specifically, the report should include
the accident, patient assessment, and interventions provided for the patient. The report
is used for internal review to improve the system to prevent similar errors and cannot be
subpoenaed by a court of law. This document remains confidential and is not part of the
, patient's medical record; thus, the incident should not be detailed in the nursing notes or
other areas of the patient chart. Although professional judgment about things such as
contributing factors should be included, personal opinions about the situation should
not.
17. A nurse is providing discharge education for a postoperative patient who will be
leaving the hospital with a urinary catheter. What statement reflects appropriate
environmental safety education for this patient?
a. "Be aware that you are at risk for falling because the catheter tubing hangs by your
feet and is a tripping hazard."
b. "Your pain medications may cause side effects including drowsiness, so be sure not
to drive while you are taking them."
c. "Because of your incisions, you should be careful to not lift anything heavier than 10
lb."
d. "Change positions slowly to avoid dizziness." - ANSWER-ANSWER: A
RATIONALE: Environmental safety hazards include patient care devices such as
catheters, surgical drains, or sequential compression devices. All other statements are
appropriate surgical discharge education but are not related to environmental safety.
17. A nurse is assessing a patient for safety upon discharge following a severe stroke.
Which of the following systems would be a priority for this patient's safety? SATA
a. Neurologic system
b. Cardiovascular system
c. Skin integrity
d. Musculoskeletal system
e. Respiratory system - ANSWER-ANSWER: A, D, E
