NURS 220 Week 2 | UPDATED Questions with 100% Verified
Answers
Q1: To which patient might the nurse apply a physical restraint? A. An 83yearold patient with dementia and
a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42yearold critical
care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74yearold
patient confined to bed who is at risk of pressure injuries. D. A 60yearold patient with dementia who
seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
A: B. A 42yearold critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
Q2: Why does the nurse instruct assistive personnel (AP) to remove the wrist restraint of a confused patient
at appropriate intervals? A. To try a less restrictive type of restraint if a more confining restraint has proved
effective B. To doublecheck the size by inserting one finger between the wrist and the restraint C. To check
the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards
A: C. To check the skin integrity and range of motion of the wrist
Q3: What would the nurse instruct assistive personnel (AP) to report when caring for a patient in a wrist
restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes
abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the
patient needs anything for pain."
A: B. "Tell me if the skin under the restraint becomes abraded or raw."
Q4: The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is
the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm
sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent
him from falling when he was at home?" D. "We will try all other alternatives before using physical
restraints."
A: D. "We will try all other alternatives before using physical restraints."
Q5: When an assistive personnel (AP) enters the room of a patient in a belt restraint, he finds the patient's
gown bunched around the patient's chest and the patient asking for help. What would the AP do? A. Check
the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the
patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like
A: B. Untie the restraint and smooth the patient's gown
, Q6: While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why
might the nurse perform this action? A. The patient is tilting the head backward while drinking. B. The patient
is choking. C. Food has dripped or spilled onto the patient's clothing. D. The nurse determines that this is the
wrong diet for the patient.
A: B. The patient is choking.
Q7: What would the nurse instruct nursing assistive personnel (NAP) to do to ensure safety when feeding
Salisbury steak to a dependent patient? A. Lower the head of the bed to a 30degree angle. B. Encourage the
patient to drink all fluids first. C. Cut the steak into small, bitesize pieces. D. Ensure that the steak is
steaming hot.
A: C. Cut the steak into small, bitesize pieces
Q8: When assisting a patient who has selffeeding difficulties, why would the nurse ask the patient to try to
selffeed? A. To determine what kind of assistance the patient needs with feeding B. To identify which food
item is causing the trouble C. To identify which hand the patient uses for utensils D. To promote the patient's
sense of selfconfidence
A: A. To determine what kind of assistance the patient needs with feeding
Q9: While feeding a patient recovering from a stroke, a nursing assistive personnel (NAP) becomes
distracted and does not watch the patient swallow a bite of food. What would the NAP do to ensure that the
patient safely swallowed the food? A. Give the patient a drink to wash down the food. B. Check the patient's
mouth for pocketing. C. Suction the patient's mouth. D. Give the patient the next bite of food.
A: B. Check the patient's mouth for pocketing.
Q10: Why would the nurse want to determine if the patient is passing flatus before giving a meal? A. To
ensure that the previous meal has been fully digested B. To ensure that the meal won't make the patient feel
uncomfortably full C. To determine whether the GI tract is functioning D. To determine whether the patient
tolerated the foods given during the previous meal
A: C. To determine whether the GI tract is functioning
Q11: When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help
maintain good skin integrity? A. Frequently applying moisturizing lotion to facial areas that come into
contact with the cannula. B. Removing the cannula every 2 hours for no longer than 10 minutes. C.
Assessing the skin of the patient's outer ears, nares, and nasal mucosa for breakdown at least once per shift.
D. Instructing the patient to inform staff of any problems with facial dryness or cracking.
A: C. Assessing the skin of the patient's outer ears, nares, and nasal mucosa for breakdown at least once per shift.
Answers
Q1: To which patient might the nurse apply a physical restraint? A. An 83yearold patient with dementia and
a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42yearold critical
care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74yearold
patient confined to bed who is at risk of pressure injuries. D. A 60yearold patient with dementia who
seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
A: B. A 42yearold critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
Q2: Why does the nurse instruct assistive personnel (AP) to remove the wrist restraint of a confused patient
at appropriate intervals? A. To try a less restrictive type of restraint if a more confining restraint has proved
effective B. To doublecheck the size by inserting one finger between the wrist and the restraint C. To check
the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards
A: C. To check the skin integrity and range of motion of the wrist
Q3: What would the nurse instruct assistive personnel (AP) to report when caring for a patient in a wrist
restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes
abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the
patient needs anything for pain."
A: B. "Tell me if the skin under the restraint becomes abraded or raw."
Q4: The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is
the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm
sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent
him from falling when he was at home?" D. "We will try all other alternatives before using physical
restraints."
A: D. "We will try all other alternatives before using physical restraints."
Q5: When an assistive personnel (AP) enters the room of a patient in a belt restraint, he finds the patient's
gown bunched around the patient's chest and the patient asking for help. What would the AP do? A. Check
the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the
patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like
A: B. Untie the restraint and smooth the patient's gown
, Q6: While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why
might the nurse perform this action? A. The patient is tilting the head backward while drinking. B. The patient
is choking. C. Food has dripped or spilled onto the patient's clothing. D. The nurse determines that this is the
wrong diet for the patient.
A: B. The patient is choking.
Q7: What would the nurse instruct nursing assistive personnel (NAP) to do to ensure safety when feeding
Salisbury steak to a dependent patient? A. Lower the head of the bed to a 30degree angle. B. Encourage the
patient to drink all fluids first. C. Cut the steak into small, bitesize pieces. D. Ensure that the steak is
steaming hot.
A: C. Cut the steak into small, bitesize pieces
Q8: When assisting a patient who has selffeeding difficulties, why would the nurse ask the patient to try to
selffeed? A. To determine what kind of assistance the patient needs with feeding B. To identify which food
item is causing the trouble C. To identify which hand the patient uses for utensils D. To promote the patient's
sense of selfconfidence
A: A. To determine what kind of assistance the patient needs with feeding
Q9: While feeding a patient recovering from a stroke, a nursing assistive personnel (NAP) becomes
distracted and does not watch the patient swallow a bite of food. What would the NAP do to ensure that the
patient safely swallowed the food? A. Give the patient a drink to wash down the food. B. Check the patient's
mouth for pocketing. C. Suction the patient's mouth. D. Give the patient the next bite of food.
A: B. Check the patient's mouth for pocketing.
Q10: Why would the nurse want to determine if the patient is passing flatus before giving a meal? A. To
ensure that the previous meal has been fully digested B. To ensure that the meal won't make the patient feel
uncomfortably full C. To determine whether the GI tract is functioning D. To determine whether the patient
tolerated the foods given during the previous meal
A: C. To determine whether the GI tract is functioning
Q11: When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help
maintain good skin integrity? A. Frequently applying moisturizing lotion to facial areas that come into
contact with the cannula. B. Removing the cannula every 2 hours for no longer than 10 minutes. C.
Assessing the skin of the patient's outer ears, nares, and nasal mucosa for breakdown at least once per shift.
D. Instructing the patient to inform staff of any problems with facial dryness or cracking.
A: C. Assessing the skin of the patient's outer ears, nares, and nasal mucosa for breakdown at least once per shift.
