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Q1. What is the very first action when you find a patient on the floor after a fall? Assess for
injury and check vital signs. Rationale: Jane Safety: Never move patient until neurovascular
status is confirmed.
Q2. What Morse Fall Scale score indicates high risk for falls? 45 or greater. Rationale:
Triggers bed alarm, yellow armband, toileting schedule.
Q3. What must be completed immediately after any fall? Incident report and post-fall huddle
note. Rationale: Real-time documentation required by HealthStream policy.
Q4. Which patient automatically requires a bed exit alarm? Patient with confusion and
previous fall history. Rationale: Jane algorithm: high risk + impaired cognition.
Q5. What is the correct head-of-bed position to prevent aspiration? 30–45 degrees. Rationale:
Reduces reflux risk; flat only if contraindicated.
Q6. When must hand hygiene be performed before patient contact? Before entering the room.
Rationale: WHO Moment 1 – even if not touching patient.
Q7. What are the three universal fall precautions applied to EVERY patient? Non-skid socks,
call light in reach, bed in low position. Rationale: Standard for all patients regardless of score.
Q8. What is missing from the handoff: “Patient fell, no injury”? Background, Assessment,
Recommendation. Rationale: Full SBAR required.
Q9. Within how many minutes must a post-fall neuro check be completed? 15 minutes.
Rationale: Jane immediate response protocol.
Q10. Which medication class significantly increases fall risk? Benzodiazepines, opioids,
antipsychotics. Rationale: Beers Criteria; flagged in Jane.
Q11. What color armband indicates high fall risk? Yellow. Rationale: Visual cue for all staff.
Q12. What is the correct response when a bed alarm sounds? Go immediately to the room.
Rationale: Never silence remotely.
, Q13. What is the key toileting question during hourly rounding? “Do you need to use the
bathroom?” Rationale: Part of 4 P’s: pain, potty, position, possessions.
Q14. What is the best non-restraint intervention for a dementia patient trying to climb out of
bed? Low bed, floor mat, family sitter. Rationale: Jane: least restrictive first.
Q15. What is the purpose of the post-fall huddle? Identify root cause and prevent future falls.
Rationale: Conducted within 24 hours.
Q16. Correct donning order for full PPE? Gown, mask/respirator, goggles, gloves. Rationale:
CDC 2025 sequence.
Q17. Correct doffing order for PPE? Gloves, goggles, gown, mask. Rationale: Most to least
contaminated.
Q18. Isolation type for MRSA wound? Contact precautions. Rationale: Gown + gloves on
room entry.
Q19. Isolation type for active pulmonary TB? Airborne + N95. Rationale: Negative pressure
room required.
Q20. Isolation type for C. difficile? Contact + soap and water. Rationale: Alcohol does not
kill spores.
Q21. Can a patient on droplet precautions leave the room? Only with surgical mask. Rationale:
COVID-19, influenza, meningitis.
Q22. How long do contact precautions continue for VRE? Until 3 negative cultures. Rationale:
Weekly screening per Jane.
Q23. Hand hygiene for norovirus outbreak? Soap and water 20 seconds. Rationale: Alcohol-
resistant virus.
Q24. Cleaning agent for C. diff room? Bleach solution or bleach wipes. Rationale: 1:10 bleach
kills spores.
Q25. When must sharps container be replaced? When ¾ full. Rationale: Prevents overfill
injury.
Q26. What color sign indicates airborne precautions? Red. Rationale: HealthStream standard.
Q27. How often is N95 fit testing required? Annually and with facial hair change. Rationale:
OSHA mandate.
Q28. Transmission route for scabies? Direct skin contact. Rationale: Contact + droplet
precautions.