NSE111 EXAM QUESTONS WITH
COMPLETE SOLUTIONS
The nurse is discussing with a patient's physician the need for restraint. The nurse
indicates that alternatives have been utilized. What behaviors would indicate that the
alternatives are working?
a. The patient continues to get up from the chair at the nurses' station.
b. The patient apologizes for being "such a bother."
c. The patient folds three washcloths over and over.
d. The sitter leaves the patient alone to go to lunch. - Answer- ANS: C
Offering diversionary activities such as something to hold is a way to keep the hands
busy and provides an alternative to restraints. Assigning a room near the nurses' station
or a chair at the desk can be an alternative for continuous monitoring. Getting up
constantly can be cause for concern. Apologizing is not an alternative to restraints.
Having a sitter sit with the patient to keep him occupied can be an alternative to
restraints, but the sitter needs to be continuous.
The nurse is caring for a patient who suddenly becomes confused and tries to remove
an intravenous infusion. The nurse begins to develop a plan to care for the patient.
Which nursing
intervention should take priority?
a. Gather restraint supplies.
b. Try alternatives to restraint.
c. Assess the patient.
d. Call the physician for a restraint order - Answer- ANS: C
When a patient becomes suddenly confused, the priority is to assess the patient,
including checking laboratory test and oxygen status and treating and eliminating the
cause of the change in mental status. If interventions and alternatives are exhausted,
the nurse working with the physician may determine the need for restraints.
The nurse knows that four categories of risk have been identified in the health care
environment. Which of the following provides the best examples of those risks?
a. Tile floors, cold food, scratchy linen, and noisy alarms
b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not
functioning properly
d. Dirty floors, hallways blocked, medication room locked, and alarms set - Answer-
ANS: C
The four categories are falls, patient-inherent accidents, procedure-related accidents,
and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is
, patient inherent, failure to use the lift is procedure related, and an alarm not functioning
properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily
contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-
inherent issues in the hospital setting but are more of patient satisfaction or infection
control issues or fire safety
issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not
procedure-related accidents. These are patient satisfaction issues and control of supply
issues, and are examples of actually following a procedure correctly. Noisy alarms, call
light within reach, and alarms set are not equipment-related accidents but are patient
satisfaction issues and examples of following a procedure correctly.
Equipment-related accidents are risks in the health care agency. The nurse assesses
for this risk when using
a. Sequential compression devices.
b. A measuring device that measures urine.
c. Computer-based documentation.
d. A manual medication-dispensing device - Answer- ANS: A
Sequential compression devices are used on a patient's extremities to assist in
prevention of deep vein thrombosis and have the potential to malfunction and harm the
patient. Measuring devices used by the nurse to measure urine, computer
documentation, and manual dispensing
devices can break or malfunction but are not used directly on a patient
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
COMPLETE SOLUTIONS
The nurse is discussing with a patient's physician the need for restraint. The nurse
indicates that alternatives have been utilized. What behaviors would indicate that the
alternatives are working?
a. The patient continues to get up from the chair at the nurses' station.
b. The patient apologizes for being "such a bother."
c. The patient folds three washcloths over and over.
d. The sitter leaves the patient alone to go to lunch. - Answer- ANS: C
Offering diversionary activities such as something to hold is a way to keep the hands
busy and provides an alternative to restraints. Assigning a room near the nurses' station
or a chair at the desk can be an alternative for continuous monitoring. Getting up
constantly can be cause for concern. Apologizing is not an alternative to restraints.
Having a sitter sit with the patient to keep him occupied can be an alternative to
restraints, but the sitter needs to be continuous.
The nurse is caring for a patient who suddenly becomes confused and tries to remove
an intravenous infusion. The nurse begins to develop a plan to care for the patient.
Which nursing
intervention should take priority?
a. Gather restraint supplies.
b. Try alternatives to restraint.
c. Assess the patient.
d. Call the physician for a restraint order - Answer- ANS: C
When a patient becomes suddenly confused, the priority is to assess the patient,
including checking laboratory test and oxygen status and treating and eliminating the
cause of the change in mental status. If interventions and alternatives are exhausted,
the nurse working with the physician may determine the need for restraints.
The nurse knows that four categories of risk have been identified in the health care
environment. Which of the following provides the best examples of those risks?
a. Tile floors, cold food, scratchy linen, and noisy alarms
b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not
functioning properly
d. Dirty floors, hallways blocked, medication room locked, and alarms set - Answer-
ANS: C
The four categories are falls, patient-inherent accidents, procedure-related accidents,
and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is
, patient inherent, failure to use the lift is procedure related, and an alarm not functioning
properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily
contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-
inherent issues in the hospital setting but are more of patient satisfaction or infection
control issues or fire safety
issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not
procedure-related accidents. These are patient satisfaction issues and control of supply
issues, and are examples of actually following a procedure correctly. Noisy alarms, call
light within reach, and alarms set are not equipment-related accidents but are patient
satisfaction issues and examples of following a procedure correctly.
Equipment-related accidents are risks in the health care agency. The nurse assesses
for this risk when using
a. Sequential compression devices.
b. A measuring device that measures urine.
c. Computer-based documentation.
d. A manual medication-dispensing device - Answer- ANS: A
Sequential compression devices are used on a patient's extremities to assist in
prevention of deep vein thrombosis and have the potential to malfunction and harm the
patient. Measuring devices used by the nurse to measure urine, computer
documentation, and manual dispensing
devices can break or malfunction but are not used directly on a patient
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
