NSE111 EXAMINATION QUESTIONS
WITH CORRECT DETAILED
ANSWERS
A patient has been admitted and placed on fall precautions. The nurse explains to the
patient that interventions for the precautions include
a. Encouraging visitors in the early evening.
b. Placing all four side rails in the "up" position.
c. Checking on the patient once a shift.
d. Placing a high risk for falls armband on the patient. - Answer- ANS: D
Placing a high risk for falls armband on the patient encourages communication among
the whole interdisciplinary team. Anyone who interacts with the patient should see this
armband, understand its meaning, and assist the patient as necessary. The timing of
visitors would not affect falls. All four side rails are considered a restraint and can
contribute to falling. Individuals on high risk for fall alerts should be checked frequently,
at least every hour
A patient with an intravenous infusion requests a new gown after bathing. Which of the
following actions is most appropriate?
a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown
and through the sleeve of the new gown, and reconnect.
b. Thread the intravenous bag and tubing through the sleeve of the old gown and
through the sleeve of the new gown without disconnecting.
c. Inform the patient that a new gown is not an option while receiving an intravenous
infusion in the hospital.
d. Call the charge nurse for assistance because linen use is monitored and this is not a
common procedure. - Answer- ANS: B
Procedure-related accidents such as contamination of sterile items can occur in the
health care setting. Keeping the intravenous tubing intact without breaks in the system
is imperative to decrease the risk of infection while changing a patient's gown and
satisfying the patient's request.
The nurse is precepting a student nurse and is careful to check with the student all
components
of the medication process. The nurse explains to the student that most errors occur in
a. Ordering and transcribing.
b. Dispensing and administering.
c. Dispensing and transcribing.
d. Ordering and administering - Answer- ANS: D
Most medication errors occur in the ordering and administering stages of the medication
process
, During the admission assessment, the nurse assesses the patient for fall risk. Which of
the
following has the greatest potential to increase the patient's risk for falls?
a. The patient is 59 years of age.
b. The patient walks 2 miles a day.
c. The patient takes Benadryl (diphenhydramine) for allergies.
d. The patient recently became widowed - Answer- ANS: C
Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a
side effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall
assessments that increase the risk for falls. Walking has many benefits, including
increasing strength, which would be beneficial in decreasing risk.
The older patient presents to the emergency department after stepping in front of a car
at a
crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of
the following comments would require follow-up by the nurse?
a. "I try to exercise, so I walk that block almost every day."
b. "I waited and stepped out when the traffic sign said go."
c. "The car was going too fast, the speed limit is 20."
d. "I was so surprised; I didn't see or hear the car coming." - Answer- ANS: D
The patient did not see or hear the car coming. As patients age, sensory impairment
can increase the risk for injury. This statement by the patient would require follow-up by
the nurse. The patient needs hearing and eye examinations. Exercise is important at
every stage of development. The patient seemed to comprehend how to cross an
intersection correctly and was able to determine the speed of the car.
The patient presents to the clinic with a family member. The family member states that
the patient has been wandering around the house and mumbling. What is the first
assessment the nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment. - Answer- ANS: B
Introduce self and engage the patient by asking her name to assess orientation; ask the
patient why she is visiting the clinic today. Continue the assessment with vital signs and
a complete workup, including a neurologic assessment.
The emergency department has been notified of a potential bioterrorist attack. The
nurse assigned to the department realizes that the most important task for safety in this
situation is to
a. Carry out the role and responsibilities of the nurse quickly and efficiently.
b. Cluster all patients with the same symptoms to a specific part of the department.
c. Determine the biologic agent and manage all patients using Standard Precautions.
d. Prepare for post-traumatic stress associated with this bioterrorist attack - Answer-
ANS: C
WITH CORRECT DETAILED
ANSWERS
A patient has been admitted and placed on fall precautions. The nurse explains to the
patient that interventions for the precautions include
a. Encouraging visitors in the early evening.
b. Placing all four side rails in the "up" position.
c. Checking on the patient once a shift.
d. Placing a high risk for falls armband on the patient. - Answer- ANS: D
Placing a high risk for falls armband on the patient encourages communication among
the whole interdisciplinary team. Anyone who interacts with the patient should see this
armband, understand its meaning, and assist the patient as necessary. The timing of
visitors would not affect falls. All four side rails are considered a restraint and can
contribute to falling. Individuals on high risk for fall alerts should be checked frequently,
at least every hour
A patient with an intravenous infusion requests a new gown after bathing. Which of the
following actions is most appropriate?
a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown
and through the sleeve of the new gown, and reconnect.
b. Thread the intravenous bag and tubing through the sleeve of the old gown and
through the sleeve of the new gown without disconnecting.
c. Inform the patient that a new gown is not an option while receiving an intravenous
infusion in the hospital.
d. Call the charge nurse for assistance because linen use is monitored and this is not a
common procedure. - Answer- ANS: B
Procedure-related accidents such as contamination of sterile items can occur in the
health care setting. Keeping the intravenous tubing intact without breaks in the system
is imperative to decrease the risk of infection while changing a patient's gown and
satisfying the patient's request.
The nurse is precepting a student nurse and is careful to check with the student all
components
of the medication process. The nurse explains to the student that most errors occur in
a. Ordering and transcribing.
b. Dispensing and administering.
c. Dispensing and transcribing.
d. Ordering and administering - Answer- ANS: D
Most medication errors occur in the ordering and administering stages of the medication
process
, During the admission assessment, the nurse assesses the patient for fall risk. Which of
the
following has the greatest potential to increase the patient's risk for falls?
a. The patient is 59 years of age.
b. The patient walks 2 miles a day.
c. The patient takes Benadryl (diphenhydramine) for allergies.
d. The patient recently became widowed - Answer- ANS: C
Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a
side effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall
assessments that increase the risk for falls. Walking has many benefits, including
increasing strength, which would be beneficial in decreasing risk.
The older patient presents to the emergency department after stepping in front of a car
at a
crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of
the following comments would require follow-up by the nurse?
a. "I try to exercise, so I walk that block almost every day."
b. "I waited and stepped out when the traffic sign said go."
c. "The car was going too fast, the speed limit is 20."
d. "I was so surprised; I didn't see or hear the car coming." - Answer- ANS: D
The patient did not see or hear the car coming. As patients age, sensory impairment
can increase the risk for injury. This statement by the patient would require follow-up by
the nurse. The patient needs hearing and eye examinations. Exercise is important at
every stage of development. The patient seemed to comprehend how to cross an
intersection correctly and was able to determine the speed of the car.
The patient presents to the clinic with a family member. The family member states that
the patient has been wandering around the house and mumbling. What is the first
assessment the nurse should do?
a. Ask the patient why she has been wandering around the house.
b. Introduce self and ask the patient her name.
c. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
d. Immediately do a complete head-to-toe neurologic assessment. - Answer- ANS: B
Introduce self and engage the patient by asking her name to assess orientation; ask the
patient why she is visiting the clinic today. Continue the assessment with vital signs and
a complete workup, including a neurologic assessment.
The emergency department has been notified of a potential bioterrorist attack. The
nurse assigned to the department realizes that the most important task for safety in this
situation is to
a. Carry out the role and responsibilities of the nurse quickly and efficiently.
b. Cluster all patients with the same symptoms to a specific part of the department.
c. Determine the biologic agent and manage all patients using Standard Precautions.
d. Prepare for post-traumatic stress associated with this bioterrorist attack - Answer-
ANS: C
