The nurse has placed a patient on high-risk alert for falls. Which of the following
observations by the nurse would indicate that the patient has an understanding of this
alert?
a. The patient removes the high alert armband to bathe.
b. The patient wears the red nonslip footwear.
c. The call light is kept on the bedside table.
d. The patient insists on taking a water pill on home schedule in the evening.
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b. The patient wears the red nonslip footwear.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
,catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care.
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a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
A nurse is teaching a community group of school-aged parents about safety. The most
important item to prioritize and explain is how to check the proper fit of
a. a bicycle helmet.
b. swimming goggles.
c. soccer shin guards.
d. baseball sliding shorts.
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a. a bicycle helmet.
The nurse is instructing the student nurse regarding discharge teaching and
medications. Which response by the student would indicate that learning has
occurred?
a. I need to be precise when teaching a patient about Zyprexa (olanzapine) and
Zyrtec (cetirizine).
b. The medications can be picked up at the pharmacy on the way out of the hospital.
c. I need to be sure to give the patient leftover medications from the medication
drawer.
d. I need to remember to teach the patient to take all medications at the same time of
the day.
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, a. I need to be precise when teaching a patient about Zyprexa (olanzapine)
and Zyrtec (cetirizine).
Which of the following concepts are important to utilize when evaluating orders for
restraints? (Select all that apply.)
a. Behaviors that necessitate the use of restraint are part of the nursing plan of care.
b. A physicians order is required for restraint and includes a face-to-face evaluation.
c. The physicians preference for the format of the order can override agency policy.
d. Orders are time limited. Restraints are not ordered prn (as needed).
e. It should be specified that restraints are to be removed periodically.
f. Restraint orders are time dated and signed by the physician.
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b, d, e, f
The nurse is teaching a group of older adults at an assisted-living facility about age-
related physiological changes. Which question would be the most important to ask
this group?
a. Are you able to hear the tornado sirens in your area?
b. Are you able to read your favorite book?
c. Are you able to remember the name of the person you just met?
d. Are you able to open a jar of pickles?
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a. Are you able to hear the tornado sirens in your area?
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
observations by the nurse would indicate that the patient has an understanding of this
alert?
a. The patient removes the high alert armband to bathe.
b. The patient wears the red nonslip footwear.
c. The call light is kept on the bedside table.
d. The patient insists on taking a water pill on home schedule in the evening.
Give this one a try later!
b. The patient wears the red nonslip footwear.
A confused patient is restless and continues to try to remove his oxygen and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this
patient?
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary
,catheter.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Caregiver role strain: Identify resources to assist with care.
Give this one a try later!
a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
A nurse is teaching a community group of school-aged parents about safety. The most
important item to prioritize and explain is how to check the proper fit of
a. a bicycle helmet.
b. swimming goggles.
c. soccer shin guards.
d. baseball sliding shorts.
Give this one a try later!
a. a bicycle helmet.
The nurse is instructing the student nurse regarding discharge teaching and
medications. Which response by the student would indicate that learning has
occurred?
a. I need to be precise when teaching a patient about Zyprexa (olanzapine) and
Zyrtec (cetirizine).
b. The medications can be picked up at the pharmacy on the way out of the hospital.
c. I need to be sure to give the patient leftover medications from the medication
drawer.
d. I need to remember to teach the patient to take all medications at the same time of
the day.
Give this one a try later!
, a. I need to be precise when teaching a patient about Zyprexa (olanzapine)
and Zyrtec (cetirizine).
Which of the following concepts are important to utilize when evaluating orders for
restraints? (Select all that apply.)
a. Behaviors that necessitate the use of restraint are part of the nursing plan of care.
b. A physicians order is required for restraint and includes a face-to-face evaluation.
c. The physicians preference for the format of the order can override agency policy.
d. Orders are time limited. Restraints are not ordered prn (as needed).
e. It should be specified that restraints are to be removed periodically.
f. Restraint orders are time dated and signed by the physician.
Give this one a try later!
b, d, e, f
The nurse is teaching a group of older adults at an assisted-living facility about age-
related physiological changes. Which question would be the most important to ask
this group?
a. Are you able to hear the tornado sirens in your area?
b. Are you able to read your favorite book?
c. Are you able to remember the name of the person you just met?
d. Are you able to open a jar of pickles?
Give this one a try later!
a. Are you able to hear the tornado sirens in your area?
The patient is confused, is trying to get out of bed, and is pulling at the intravenous
infusion tubing. These data would help to support a nursing diagnosis of
