NUR 242 Exam #2
Study online at https://quizlet.com/_9dsapl
1. While making rounds, the nurse finds a patient on the -assess the patient for in-
floor in the hallway. Which action will the nurse do jury
first?
-assess the patient for injury
-transfer the patient back to bed
-assist the patient to a wheelchair
-report the patient's condition to the physician
2. Which action should the nurse take to prevent acci- -determine the strength of
dents? the patient
-apply a restraint when the patient is in the wheelchair
to keep them from falling
-determine the strength of the patient
-turn all the lights off in the room so the patient can
sleep
-provide a cane for walking if the patient is weak
3. When caring for a patient who is able to get out of bed -leave one side rail up
independently and safely, the nurse will when there are only two
-leave one side rail at the foot of the bed up side rails on the bed
-leave one side rail up when there are only two side
rails on the bed
-leave both side rails up in a two side rail bed
-leave all four side rails up for all patients at all times
4. The nurse is monitoring for Never Events. Which find- -a sponge is left in the pa-
ing indicates the nurse will report a Never Event? tient's incision
-a sponge is left in the patient's incision
-pulmonary embolism after lung surgery
-no blood incompatibility occurs with a blood transfu-
sion
-development of stage II pressure ulcer
1/6
, NUR 242 Exam #2
Study online at https://quizlet.com/_9dsapl
5. The nurse discovers a patient on the floor. The patient -notify the health care
states that he fell out of bed. The nurse assesses the provider
patient and finds no apparent changes in the previous
assessment. The nurse assists the patient back to bed.
Which action should the nurse take next?
-notify the health care provider
-do nothing, no harm has occurred
-notify the family
-complete an incident report
6. The nurse is teaching a group of older adults at an -Are you able to hear
assisted living facility about age related physiological the tornado sirens in your
changes affecting safety. Which question would be area?
most important for the nurse to ask this group?
-Are you able to taste spices like before?
-Are you able to hear the tornado sirens in your area?
-Are you able to read the newspaper?
-Are you able to open a jar of pickles?
7. The nurse is trying to use diversion rather than restrain -the patient folds three
a patient. Which finding will cause the nurse to deter- washcloths over and over
mine the diversion is working?
-the patient apologizes for being "such a bother"
-the patient folds three washcloths over and over
-the patient gets restless when the sitter leaves for
lunch
-the patient continues to get up from the chair at the
nurse's station
8. The nurse is caring for a patient who suddenly be- -assess the patient
comes confused and tries to remove a wound dress-
ing. Which priority action will the nurse take?
2/6
Study online at https://quizlet.com/_9dsapl
1. While making rounds, the nurse finds a patient on the -assess the patient for in-
floor in the hallway. Which action will the nurse do jury
first?
-assess the patient for injury
-transfer the patient back to bed
-assist the patient to a wheelchair
-report the patient's condition to the physician
2. Which action should the nurse take to prevent acci- -determine the strength of
dents? the patient
-apply a restraint when the patient is in the wheelchair
to keep them from falling
-determine the strength of the patient
-turn all the lights off in the room so the patient can
sleep
-provide a cane for walking if the patient is weak
3. When caring for a patient who is able to get out of bed -leave one side rail up
independently and safely, the nurse will when there are only two
-leave one side rail at the foot of the bed up side rails on the bed
-leave one side rail up when there are only two side
rails on the bed
-leave both side rails up in a two side rail bed
-leave all four side rails up for all patients at all times
4. The nurse is monitoring for Never Events. Which find- -a sponge is left in the pa-
ing indicates the nurse will report a Never Event? tient's incision
-a sponge is left in the patient's incision
-pulmonary embolism after lung surgery
-no blood incompatibility occurs with a blood transfu-
sion
-development of stage II pressure ulcer
1/6
, NUR 242 Exam #2
Study online at https://quizlet.com/_9dsapl
5. The nurse discovers a patient on the floor. The patient -notify the health care
states that he fell out of bed. The nurse assesses the provider
patient and finds no apparent changes in the previous
assessment. The nurse assists the patient back to bed.
Which action should the nurse take next?
-notify the health care provider
-do nothing, no harm has occurred
-notify the family
-complete an incident report
6. The nurse is teaching a group of older adults at an -Are you able to hear
assisted living facility about age related physiological the tornado sirens in your
changes affecting safety. Which question would be area?
most important for the nurse to ask this group?
-Are you able to taste spices like before?
-Are you able to hear the tornado sirens in your area?
-Are you able to read the newspaper?
-Are you able to open a jar of pickles?
7. The nurse is trying to use diversion rather than restrain -the patient folds three
a patient. Which finding will cause the nurse to deter- washcloths over and over
mine the diversion is working?
-the patient apologizes for being "such a bother"
-the patient folds three washcloths over and over
-the patient gets restless when the sitter leaves for
lunch
-the patient continues to get up from the chair at the
nurse's station
8. The nurse is caring for a patient who suddenly be- -assess the patient
comes confused and tries to remove a wound dress-
ing. Which priority action will the nurse take?
2/6
