NSE 221 TEST 1 QUESTIONS & ANSWERS
What does race stand for? - answers :rescue, alarm, confine, extinguish
What does pass stand for? - answers :pull the pin, aim, squeeze, sweep
If seizures occur what do you do? - answers :always stay with the patient, call for help, if
standing, guide to the floor and cradle head in lap or place pad under head, provide
privacy, turn patient on side if able with head tilted and slightly forward, do not place
anything in mouth, note time seizure starts, ends, and the patients behavior, maintain
patent airway, suction, and apply oxygen by nasal cannula
What is the assessment for falls risk? - answers :poor vision, cognitive dysfunction,
impaired mobility, urinary frequency, physical condition, medications, age, history of
falls
How do you prevent falls? - answers :side rails up when appropriate, bed low
position/wheels locked, call bell in reach, glasses, hearing aids, ambulatory aids in use,
room clutter free, clean up spills, electrical safety good lighting, provide non-skid
footwear for clients
What are the 6 p's of rounding? - answers :pain, potty, position, personal items, plan,
place call bell in reach, ask: is there anything else?
What things should you orient your patient to? - answers :room, equipment, call
bell/emergency bell, telephone, tv/radio, side rails, safety measures, visiting hours, unit
routine, including meals
What are examples of safe transfers? - answers :from bed to chair, and from bed to
stretcher
When is it okay to use a restraint? - answers :as a last resort to provide patient safety or
safety of others
What might chemical restraints do to the elderly? - answers :may cause confusion
What are physical restraints? - answers :a physical device attached to the body to
restrict movement/activity for safety
What do you assess when using restraints? - answers :mental status, pain, education
level and understanding of client, therapy needed, determine need for restraint
What needs to be determined for a use of a restraint? - answers :if behavior may
interrupt therapy, or if there is a threat to self or others
, What are some safety measures when using restraints? - answers :inspect client for
injury per policy, check neurological and circulatory status, ensure restraint is secure but
not restrictive loose enough for two fingers to fit between restraint, never tie to bed rails
(use quick release knot), explain need for restraint to client and family, never leave
client alone if restraint is removed temporarily, orders are required, reassess for q 24
hours.
When can a order be obtained after a restraint is applied? - answers :in emergency
situations like er or icu
What must you document when using restraints? - answers :what behavior required
restraint, type of restraint applied, education provided to family/client, clients consent if
required policy, times of application and removal, assessment of client, limb, rom,
assessment of therapy, review physician order for changes/updates
Does 4 side rails up equal a physical restraint? - answers :no
What does body mechanics and alignment also refer to? - answers :posture,
coordinated efforts of the musculoskeletal and nervous systems, sitting, standing, or
lying
What is the nature of infection? - answers :infection is the invasion of a susceptible host
by pathogens or microorganisms, resulting in disease; entry and multiplication of
organisms result in disease; colonization occurs when a microorganism invades the
host but does not cause infection; communicable disease is the infectious process
transmitted from one person to another; if pathogens multiply and cause clinical signs
and symptoms, the infection is symptomatic; if clinical signs and symptoms are not
present, the illness is termed asymptomatic; hand hygiene is the most important
technique to use in preventing and controlling transmission of infection
What is the cycle of infection? - answers :infectious agent or pathogen, reservoir or
source for pathogen growth, portal of exit, mode of transmission, portal of entry,
susceptible host
What are the stages of infection? - answers :incubation, prodromal stage, illness stage,
convalescence
Incubation - answers :interval between the pathogen entering the body and presentation
of the first symptom
Prodromal stage - answers :interval from onset of general symptoms to more distinct
symptoms. During this time the pathogen is multiplying
Illness stage - answers :interval when symptoms specific to the infection occur
What does race stand for? - answers :rescue, alarm, confine, extinguish
What does pass stand for? - answers :pull the pin, aim, squeeze, sweep
If seizures occur what do you do? - answers :always stay with the patient, call for help, if
standing, guide to the floor and cradle head in lap or place pad under head, provide
privacy, turn patient on side if able with head tilted and slightly forward, do not place
anything in mouth, note time seizure starts, ends, and the patients behavior, maintain
patent airway, suction, and apply oxygen by nasal cannula
What is the assessment for falls risk? - answers :poor vision, cognitive dysfunction,
impaired mobility, urinary frequency, physical condition, medications, age, history of
falls
How do you prevent falls? - answers :side rails up when appropriate, bed low
position/wheels locked, call bell in reach, glasses, hearing aids, ambulatory aids in use,
room clutter free, clean up spills, electrical safety good lighting, provide non-skid
footwear for clients
What are the 6 p's of rounding? - answers :pain, potty, position, personal items, plan,
place call bell in reach, ask: is there anything else?
What things should you orient your patient to? - answers :room, equipment, call
bell/emergency bell, telephone, tv/radio, side rails, safety measures, visiting hours, unit
routine, including meals
What are examples of safe transfers? - answers :from bed to chair, and from bed to
stretcher
When is it okay to use a restraint? - answers :as a last resort to provide patient safety or
safety of others
What might chemical restraints do to the elderly? - answers :may cause confusion
What are physical restraints? - answers :a physical device attached to the body to
restrict movement/activity for safety
What do you assess when using restraints? - answers :mental status, pain, education
level and understanding of client, therapy needed, determine need for restraint
What needs to be determined for a use of a restraint? - answers :if behavior may
interrupt therapy, or if there is a threat to self or others
, What are some safety measures when using restraints? - answers :inspect client for
injury per policy, check neurological and circulatory status, ensure restraint is secure but
not restrictive loose enough for two fingers to fit between restraint, never tie to bed rails
(use quick release knot), explain need for restraint to client and family, never leave
client alone if restraint is removed temporarily, orders are required, reassess for q 24
hours.
When can a order be obtained after a restraint is applied? - answers :in emergency
situations like er or icu
What must you document when using restraints? - answers :what behavior required
restraint, type of restraint applied, education provided to family/client, clients consent if
required policy, times of application and removal, assessment of client, limb, rom,
assessment of therapy, review physician order for changes/updates
Does 4 side rails up equal a physical restraint? - answers :no
What does body mechanics and alignment also refer to? - answers :posture,
coordinated efforts of the musculoskeletal and nervous systems, sitting, standing, or
lying
What is the nature of infection? - answers :infection is the invasion of a susceptible host
by pathogens or microorganisms, resulting in disease; entry and multiplication of
organisms result in disease; colonization occurs when a microorganism invades the
host but does not cause infection; communicable disease is the infectious process
transmitted from one person to another; if pathogens multiply and cause clinical signs
and symptoms, the infection is symptomatic; if clinical signs and symptoms are not
present, the illness is termed asymptomatic; hand hygiene is the most important
technique to use in preventing and controlling transmission of infection
What is the cycle of infection? - answers :infectious agent or pathogen, reservoir or
source for pathogen growth, portal of exit, mode of transmission, portal of entry,
susceptible host
What are the stages of infection? - answers :incubation, prodromal stage, illness stage,
convalescence
Incubation - answers :interval between the pathogen entering the body and presentation
of the first symptom
Prodromal stage - answers :interval from onset of general symptoms to more distinct
symptoms. During this time the pathogen is multiplying
Illness stage - answers :interval when symptoms specific to the infection occur
