Germanna Community College | Complete 200-Question Test
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EXAM 2 BLUEPRINT
Approximate
Topic Area Percentage
Questions
Safety & Fall Prevention 20% 40
Infection Control & PPE 15% 30
Restraints & Seizure Precautions 10% 20
Functional Ability & ADLs 10% 20
Nursing Process & Clinical
15% 30
Judgment
Medication Administration 10% 20
Communication &
10% 20
Documentation
NGN Case Scenarios (Integrated) 10% 20
,SECTION 1: SAFETY & FALL PREVENTION (Questions 1–40)
1. A nurse is implementing fall precautions for an older adult
patient. Which action is most appropriate?
A) Keep all four side rails up at night
B) Place the bed in the lowest position with locked wheels
C) Encourage the patient to wear non-skid socks only during the
day
D) Keep the call light on the bedside table
Answer: B) Place the bed in the lowest position with locked
wheels
Rationale: The bed should be in the lowest position and wheels
locked to reduce injury from falls. Side rails up (A) is considered
a restraint. Non-skid socks should be worn anytime the patient
is out of bed. The call light must be within easy reach, attached
to the gown or pillow.
2. Which patient is at the highest risk for falling?
A) 45-year-old post-operative day 1
B) 70-year-old with history of stroke and taking
antihypertensives
,C) 30-year-old with a broken ankle using crutches
D) 80-year-old with mild hearing loss
Answer: B) 70-year-old with history of stroke and taking
antihypertensives
Rationale: The 70-year-old has multiple risk factors: advanced
age, history of stroke (hemiparesis/neglect), and
antihypertensive medications (orthostatic hypotension).
Hearing loss alone (D) is a lower risk factor.
3. A patient uses a cane. The nurse should instruct the patient
to hold the cane on which side?
A) The weaker side
B) The stronger side
C) The side with most pain
D) The contralateral side to the affected leg
Answer: B) The stronger side
Rationale: The cane is held on the stronger side (contralateral
to the weak leg) to widen the base of support and reduce the
load on the weak side. Both B and D are correct as they
describe the same concept.
4. The nurse is educating a patient on home fire safety. Which
statement indicates understanding?
A) "I will use a space heater only when I am sleeping."
, B) "I willreplacemysmokedetectorbatteries every 5 years."
C) "I should haveafireescape plan with two ways out of each
room."
D) "I will keep a fire extinguisher in thekitchen only."
Answer: C) "I should haveafire escape plan with two ways out of
each room."
Rationale: Afire escape plan with two ways out of each room is
essential for home fire safety. Smokedetectorbatteries should be
replaced annually, notevery 5 years. Space heaters should never
beusedwhilesleeping.
5. Aclient is on seizureprecautions. Whichitem should bekeptat
thebedside?
A) Oralairway and suction equipment
B) Restraintkit
C) Hard mouth guard
D) Oxygen mask
Answer: A) Oralairway and suction equipment
Rationale: Suction and anoralairwayareneeded to maintainthe
airway during aseizure. Never place hard objects in the mouth
(C)—can break teeth orcauseaspiration.
6. Apatient is using a walker. Which gait pattern is correctfora
patientwith bilateralleg weakness?