Safety Exam Questions With All Correct And
Verified Answers
What is the purpose of a gait belt?
It keeps patients from ambulating too fast by holding onto them.
It measures the distance a patient has ambulated by counting steps.
It provides a means to steady a patient at the center of gravity.
It identifies patients who are at risk for a fall and require assistance.
It is a type of restraint used as a safety measure. Correct answer-It provides a means to steady a
patient at the center of gravity.
A gait belt is used to transfer a patient safely or as a safety measure to steady a patient who has poor
balance. NAP or nurses may use a gait belt.
A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the
assistance of security, the charge nurse places wrist restraints on the patient. What would be a
priority action at this time?
Notify the health care provider for follow-up evaluation.
Tie the restraint straps in a knot so the patient does not get loose.
Tie the restraints to the bedside rail or frame of the wheelchair.
Assess, but avoid removing the restraints every 2 hours because the patient is violent. Correct
answer-Notify the health care provider for follow-up evaluation.
When a restraint is used for violent or self-destructive behavior, a licensed health care provider must
evaluate the patient in person within 1 hour of the initiation of restraints and orders obtained.
Restraints should be tied to the movable frame of the bed so if the position of the head of bed is
changed, the patient's extremity will not be compromised. Restraints should never be tied to the side
rail. Restraints should be secured with a quick-release tie in case of an emergency. The restraints
should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a
time or have staff assistance.
The patient begins to cough and choke while the nurse is feeding him. What should the nurse do?
Give the patient some water.
Allow the patient to rest.
Suction the airway as necessary.
Notify the health care provider immediately. Correct answer-Suction the airway as necessary.
The nurse should first use suction equipment if necessary to clear food from the airway and position
the patient in the high-Fowler's position or, if unable to do so, position the patient on the patient's
side. If choking occurs repeatedly, stop feeding the patient and notify the health care provider.
Provide oxygen if the patient's color has failed to return to normal. Offering the patient water may
only increase choking, because thin liquids such as water and fruit juice are difficult to control in the
mouth and are more easily aspirated. As a preventive measure, the nurse should allow the patient to
rest throughout feeding.
A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery
and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would
likely be the least restrictive and most effective?
, Belt restraint.
Extremity restraint.
Mitten restraint.
Elbow restraint. Correct answer-Elbow restraint.
Elbow restraints are used to prevent a patient (usually a child) from reaching the head and face area
to pull at stitches and tubes or scratch at skin irritations. A belt restraint secures a patient in bed or
on a stretcher. An extremity/limb restraint (wrist or ankle) may be used to immobilize one or all
extremities. A mitten restraint is a thumbless mitten device to restrain a patient's hands. It is used to
prevent the use of fingers to scratch the skin, remove dressings, or dislodge equipment, yet allows
more movement than a wrist restraint.
What should the nurse do prior to applying physical restraints?
Move the patient to a room without a roommate and away from the nurses' station.
Warn the patient that restraints will be used if he or she does not cooperate.
Initially, provide a restraint-free environment.
Wait until the patient has actually fallen. Correct answer-Initially, provide a restraint-free
environment.
The standard of care for institutionalized older adults is avoidance of mechanical restraints except as
needed under exceptional circumstances and only after all other reasonable alternatives have been
tried. Creating fear in the patient and stating restraints will be used as a punishment can be
considered assault. The patient should be provided with the least restrictive environment, and close
monitoring would be wise. Restraints are to be used only after all other reasonable alternatives have
been tried. If the nurse waits until the patient has actually fallen, the patient could sustain an injury.
Although restraints are to be used only after all other reasonable alternatives have been tried, it is
unreasonable to wait until the patient sustains a fall.
The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the
following is inaccurate information that should not be included in the discussion?
Restraints provide a reliable method to prevent falls without serious complications.
Attach the restraint to the movable part of the bed frame.
When all side rails are raised, this may be considered a form of physical restraint.
Two fingers should be able to fit underneath the restraint. Correct answer-Restraints provide a
reliable method to prevent falls without serious complications.
The use of restraints is associated with serious complications, including pressure ulcers, constipation,
urinary and fecal incontinence, and pneumonia. In some cases, restricted breathing or circulation has
resulted in death. Loss of self-esteem and a sense of humiliation, fear, and anger are additional
serious concerns. Side rails may be considered a restraint device when used to prevent the
ambulatory patient from getting out of bed. Check agency policy. Using two fingers to check the fit of
a restraint guarantees safe application and prevents neurovascular compromise. Restraints should
not be attached to the bedside rails but should be attached to the portion of the bed frame that will
move when the head of the bed is raised or lowered to prevent patient injury.
A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed
should the nurse place the wheelchair?
Verified Answers
What is the purpose of a gait belt?
It keeps patients from ambulating too fast by holding onto them.
It measures the distance a patient has ambulated by counting steps.
It provides a means to steady a patient at the center of gravity.
It identifies patients who are at risk for a fall and require assistance.
It is a type of restraint used as a safety measure. Correct answer-It provides a means to steady a
patient at the center of gravity.
A gait belt is used to transfer a patient safely or as a safety measure to steady a patient who has poor
balance. NAP or nurses may use a gait belt.
A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the
assistance of security, the charge nurse places wrist restraints on the patient. What would be a
priority action at this time?
Notify the health care provider for follow-up evaluation.
Tie the restraint straps in a knot so the patient does not get loose.
Tie the restraints to the bedside rail or frame of the wheelchair.
Assess, but avoid removing the restraints every 2 hours because the patient is violent. Correct
answer-Notify the health care provider for follow-up evaluation.
When a restraint is used for violent or self-destructive behavior, a licensed health care provider must
evaluate the patient in person within 1 hour of the initiation of restraints and orders obtained.
Restraints should be tied to the movable frame of the bed so if the position of the head of bed is
changed, the patient's extremity will not be compromised. Restraints should never be tied to the side
rail. Restraints should be secured with a quick-release tie in case of an emergency. The restraints
should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a
time or have staff assistance.
The patient begins to cough and choke while the nurse is feeding him. What should the nurse do?
Give the patient some water.
Allow the patient to rest.
Suction the airway as necessary.
Notify the health care provider immediately. Correct answer-Suction the airway as necessary.
The nurse should first use suction equipment if necessary to clear food from the airway and position
the patient in the high-Fowler's position or, if unable to do so, position the patient on the patient's
side. If choking occurs repeatedly, stop feeding the patient and notify the health care provider.
Provide oxygen if the patient's color has failed to return to normal. Offering the patient water may
only increase choking, because thin liquids such as water and fruit juice are difficult to control in the
mouth and are more easily aspirated. As a preventive measure, the nurse should allow the patient to
rest throughout feeding.
A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery
and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would
likely be the least restrictive and most effective?
, Belt restraint.
Extremity restraint.
Mitten restraint.
Elbow restraint. Correct answer-Elbow restraint.
Elbow restraints are used to prevent a patient (usually a child) from reaching the head and face area
to pull at stitches and tubes or scratch at skin irritations. A belt restraint secures a patient in bed or
on a stretcher. An extremity/limb restraint (wrist or ankle) may be used to immobilize one or all
extremities. A mitten restraint is a thumbless mitten device to restrain a patient's hands. It is used to
prevent the use of fingers to scratch the skin, remove dressings, or dislodge equipment, yet allows
more movement than a wrist restraint.
What should the nurse do prior to applying physical restraints?
Move the patient to a room without a roommate and away from the nurses' station.
Warn the patient that restraints will be used if he or she does not cooperate.
Initially, provide a restraint-free environment.
Wait until the patient has actually fallen. Correct answer-Initially, provide a restraint-free
environment.
The standard of care for institutionalized older adults is avoidance of mechanical restraints except as
needed under exceptional circumstances and only after all other reasonable alternatives have been
tried. Creating fear in the patient and stating restraints will be used as a punishment can be
considered assault. The patient should be provided with the least restrictive environment, and close
monitoring would be wise. Restraints are to be used only after all other reasonable alternatives have
been tried. If the nurse waits until the patient has actually fallen, the patient could sustain an injury.
Although restraints are to be used only after all other reasonable alternatives have been tried, it is
unreasonable to wait until the patient sustains a fall.
The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the
following is inaccurate information that should not be included in the discussion?
Restraints provide a reliable method to prevent falls without serious complications.
Attach the restraint to the movable part of the bed frame.
When all side rails are raised, this may be considered a form of physical restraint.
Two fingers should be able to fit underneath the restraint. Correct answer-Restraints provide a
reliable method to prevent falls without serious complications.
The use of restraints is associated with serious complications, including pressure ulcers, constipation,
urinary and fecal incontinence, and pneumonia. In some cases, restricted breathing or circulation has
resulted in death. Loss of self-esteem and a sense of humiliation, fear, and anger are additional
serious concerns. Side rails may be considered a restraint device when used to prevent the
ambulatory patient from getting out of bed. Check agency policy. Using two fingers to check the fit of
a restraint guarantees safe application and prevents neurovascular compromise. Restraints should
not be attached to the bedside rails but should be attached to the portion of the bed frame that will
move when the head of the bed is raised or lowered to prevent patient injury.
A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed
should the nurse place the wheelchair?
