NURS 2030: Exam 2: Safety & Mobility, Elimination &
Nutrition, and I & O- Questions and Answers
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Terms in this set (310)
What are the two patient identifiers Full name and date of birth (or MRN); never room number.
required before providing care or
administering medication?
An event that could have caused harm but did not, either by chance or timely
What is a near miss?
intervention.
Any process, act, or omission that results in, or has the potential to result in, harm to
What is a patient safety event?
a patient.
A patient safety event that results in death, permanent harm, or severe temporary
What is a sentinel event?
harm.
Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection (CAUTI),
What are the three most common HAIs?
Central Line-Associated Bloodstream Infection (CLABSI).
What should a nurse do if a blood Stop the transfusion immediately, keep IV access with normal saline, notify the
transfusion reaction is suspected? provider, and monitor the patient.
Which identifiers are verified before Two identifiers (name and DOB or MRN) against the order and blood product—never
starting a blood transfusion? room number.
What should be monitored at the start of a Vital signs at baseline and again 15 minutes after starting; nurse should stay with
blood transfusion? patient to observe.
What is the Morse Fall Scale used for? To assess a patient's risk of falling.
What is the Braden Scale used for? To assess a patient's risk of pressure injury/ulcer.
Name three client factors that increase fall Stroke, weakness/unsteady gait, visual impairment.
risk.
Name two cognitive factors that increase Disorientation/dementia, sleep disorders.
fall risk.
, Name two environmental factors that Clutter and poor lighting.
increase fall risk.
Name two other factors that increase fall Older age and frequent bathroom needs/incontinence.
risk.
Fall prevention interventions include (name Non-skid footwear, bed in low position, call light within reach.
3).
What are the main types of restraints? Physical, chemical, barrier (e.g., side rails), and seclusion.
Alternatives like distraction, sitter, socialization, or placing patient near nurses'
What must be attempted before restraints?
station.
Patient poses harm to self or others; requires documentation and frequent
What are valid indications for restraints?
reassessment.
What must be assessed frequently for Circulation, skin integrity, vital signs, and comfort/safety.
restrained patients?
What are key nursing actions with Ensure restraints are not too tight, remove during assessments, support
restraints? hygiene/nutrition/ROM, and document.
Name three seizure precautions. Pad bed rails, suction and oxygen at bedside, establish IV access.
During a seizure, what position should the Side-lying to maintain airway and prevent aspiration.
patient be placed in?
What should the nurse monitor during a Start time, duration, activity, body parts involved, eye changes, VS, incontinence.
seizure?
What must the nurse never do during a Insert objects into the mouth or restrain movement.
seizure?
What equipment/safe handling is Mechanical lifts, slide sheets, multiple personnel assistance, bariatric equipment.
recommended for bariatric clients?
What are key anticoagulant safety Monitor labs (INR/aPTT, renal/hepatic), weight, dosage, and interactions; educate on
measures? food-drug interactions and bleeding risk.
Which anticoagulant meds require extreme Warfarin, heparin, enoxaparin.
caution?
What conditions are treated with DVT, PE, atrial fibrillation, stroke, and mechanical heart valves.
anticoagulants?
What should patients on anticoagulants be Report bleeding, avoid NSAIDs/aspirin unless prescribed, maintain consistent
taught? vitamin K, keep lab/follow-up appointments.
What are common hazards to assess during Loose rugs, poor lighting, clutter, unsafe stairs, no grab bars, improper storage of
a home safety evaluation? medications.
What is the purpose of a surgical time-out? To prevent wrong patient, wrong procedure, and wrong site/side events.
When is a surgical time-out performed? Immediately before the procedure or incision begins.
Who participates in a surgical time-out? The entire surgical team (surgeon, anesthesia, nurses, scrub staff).
What should the nurse do if a mismatch is Stop the procedure until the discrepancy is resolved.
found during time-out?
What are appropriate interventions to Pre-op antibiotics on time, sterile technique, skin prep, aseptic wound care.
prevent SSI?
Use catheters only when necessary, maintain closed system, catheter care, remove
What are best practices to prevent CAUTI?
promptly.
What are best practices to prevent Sterile insertion, site care, scrub the hub, assess daily for line necessity.
CLABSI?
Nutrition, and I & O- Questions and Answers
Save
Terms in this set (310)
What are the two patient identifiers Full name and date of birth (or MRN); never room number.
required before providing care or
administering medication?
An event that could have caused harm but did not, either by chance or timely
What is a near miss?
intervention.
Any process, act, or omission that results in, or has the potential to result in, harm to
What is a patient safety event?
a patient.
A patient safety event that results in death, permanent harm, or severe temporary
What is a sentinel event?
harm.
Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection (CAUTI),
What are the three most common HAIs?
Central Line-Associated Bloodstream Infection (CLABSI).
What should a nurse do if a blood Stop the transfusion immediately, keep IV access with normal saline, notify the
transfusion reaction is suspected? provider, and monitor the patient.
Which identifiers are verified before Two identifiers (name and DOB or MRN) against the order and blood product—never
starting a blood transfusion? room number.
What should be monitored at the start of a Vital signs at baseline and again 15 minutes after starting; nurse should stay with
blood transfusion? patient to observe.
What is the Morse Fall Scale used for? To assess a patient's risk of falling.
What is the Braden Scale used for? To assess a patient's risk of pressure injury/ulcer.
Name three client factors that increase fall Stroke, weakness/unsteady gait, visual impairment.
risk.
Name two cognitive factors that increase Disorientation/dementia, sleep disorders.
fall risk.
, Name two environmental factors that Clutter and poor lighting.
increase fall risk.
Name two other factors that increase fall Older age and frequent bathroom needs/incontinence.
risk.
Fall prevention interventions include (name Non-skid footwear, bed in low position, call light within reach.
3).
What are the main types of restraints? Physical, chemical, barrier (e.g., side rails), and seclusion.
Alternatives like distraction, sitter, socialization, or placing patient near nurses'
What must be attempted before restraints?
station.
Patient poses harm to self or others; requires documentation and frequent
What are valid indications for restraints?
reassessment.
What must be assessed frequently for Circulation, skin integrity, vital signs, and comfort/safety.
restrained patients?
What are key nursing actions with Ensure restraints are not too tight, remove during assessments, support
restraints? hygiene/nutrition/ROM, and document.
Name three seizure precautions. Pad bed rails, suction and oxygen at bedside, establish IV access.
During a seizure, what position should the Side-lying to maintain airway and prevent aspiration.
patient be placed in?
What should the nurse monitor during a Start time, duration, activity, body parts involved, eye changes, VS, incontinence.
seizure?
What must the nurse never do during a Insert objects into the mouth or restrain movement.
seizure?
What equipment/safe handling is Mechanical lifts, slide sheets, multiple personnel assistance, bariatric equipment.
recommended for bariatric clients?
What are key anticoagulant safety Monitor labs (INR/aPTT, renal/hepatic), weight, dosage, and interactions; educate on
measures? food-drug interactions and bleeding risk.
Which anticoagulant meds require extreme Warfarin, heparin, enoxaparin.
caution?
What conditions are treated with DVT, PE, atrial fibrillation, stroke, and mechanical heart valves.
anticoagulants?
What should patients on anticoagulants be Report bleeding, avoid NSAIDs/aspirin unless prescribed, maintain consistent
taught? vitamin K, keep lab/follow-up appointments.
What are common hazards to assess during Loose rugs, poor lighting, clutter, unsafe stairs, no grab bars, improper storage of
a home safety evaluation? medications.
What is the purpose of a surgical time-out? To prevent wrong patient, wrong procedure, and wrong site/side events.
When is a surgical time-out performed? Immediately before the procedure or incision begins.
Who participates in a surgical time-out? The entire surgical team (surgeon, anesthesia, nurses, scrub staff).
What should the nurse do if a mismatch is Stop the procedure until the discrepancy is resolved.
found during time-out?
What are appropriate interventions to Pre-op antibiotics on time, sterile technique, skin prep, aseptic wound care.
prevent SSI?
Use catheters only when necessary, maintain closed system, catheter care, remove
What are best practices to prevent CAUTI?
promptly.
What are best practices to prevent Sterile insertion, site care, scrub the hub, assess daily for line necessity.
CLABSI?
