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What type of authority regulates the practice of nursing? ✔Correct Answer-State nurse practice
acts
In meeting the safty of needs of the adolescent client, it would be most important for the nurse to
focus her teaching on ✔Correct Answer-Drivers education ( most cause of death is because of car
accident--- WEAR SEATBELT)
How often should restraints be removed? ✔Correct Answer-at least ever two hours
What is the protocol when removing restraints? ✔Correct Answer-The nurse should stay with the
patient when the restraint is removed, offer fluids and assistance with toileting, and check for
adverse physiological effects from the restraint.
What can the nurse delegate to the CNA/UAP regarding restraints? ✔Correct Answer-The nurse
can delegate the checks and releases to a certified nursing assistant (CNA) or UAP.
What is the CNA/UAP not allowed to do? ✔Correct Answer-The UAP cannot teach, educate, or
assess the patient.
Restraints should only be tied to ✔Correct Answer-A moving part of the bed
The 6 factors that contribute to an unsafe patient environment. ✔Correct Answer-1. Age & ability
to understand
2. Impaired mobility
3. Communication
4. Pain & discomfort
5. Delayed assistance
6. Equipment
Why are the elderly more at risk for falls when they are hospitalized? ✔Correct Answer-They may
be confused for a variety of reasons including unfamiliar surroundings and medications. When they
get up, they may not realize that they are attached to tubes and cords, so they may pull them or trip
over them. They may not clearly understand or remember directions from nurses such as not to get
up without help.
Answering patients call lights promptly is a safety issue. Defend this statement. ✔Correct Answer-If
a patient does not get assistance in a timely manner, he or she may attempt to get up and walk alone
when it is not safe to do so. This leads to falls and injuries that could have been prevented.
Discuss the role of nurses in a mass casualty event. ✔Correct Answer-A student nurse's
responsibility as a student and as a nurse will be to know and follow his or her facility's disaster plan.
A student nurse should expect to be called in to work as an extra if a disaster occurs. It is appropriate
for the student nurse to ensure the safety of family first and then assist at his or her place of work.
Some facilities have a plan for calling in extra help according to needs, rather than having a barrage
of off-duty employees arriving at once.
, Researchers have found that, because they are more likely than others to move around in bed or try
to get out of bed, the individuals who are at highest risk for entrapment are older, frail adults who
experience ✔Correct Answer-Pain, Confusion, Fecal Impaction, Urinary retention
The nurse is caring for a patient who has a history of getting up without assistance, which results in
falls. The nurse selects a restraint alternative for this patient. Restraint alternatives include...
✔Correct Answer-Leg Monitors, bed monitors, chair monitors
When an order has been obtained to place restraints on a patient, and the restraints are in place,
nursing staff is required by the Health Care Financing Administration (HCFA) and the Joint
Commission to follow guidelines, which include ✔Correct Answer-1. Offering the patient fluids.
2. Assisting the patient with toileting.
3. Changing the patient's position in bed.
4. Removing the restraint every 2 hours.
6. Assessing the patient's extremities for edema, capillary refill, and sensation.
When providing discharge instructions to a patient who has been prescribed home oxygen therapy,
the nurse teaches the patient to ✔Correct Answer-3. Avoid smoking near the oxygen source.
4. Avoid wearing wool blankets or sweaters.
5. Use extension tubing to move around the house.
When educating a class of nursing students about using good body mechanics and injury prevention,
the nursing instructor teaches them to ✔Correct Answer-1. Plan work carefully.
2. Elevate work to a comfortable level.
3. Hold an object close and bend their elbows when carrying something.
A student nurse is out shopping when he or she hears that a mass casualty event (MCE) has occurred
in the area. It is his or her responsibility as a student and as a nurse to ✔Correct Answer-A student
nurse should expect to be called in to work as an extra if a disaster occurs. It is appropriate for the
student nurse to ensure the safety of family first and then assist at his or her place of work. Some
facilities have a plan for calling in extra help according to needs, rather than having a barrage of off-
duty employees arriving at once.
which aspect of restraints can a nurse delecate to a nursing assistant? ✔Correct Answer-they can
remove the restraint to make sure the skin is intact
Which one of the following foods should the nurse recommend for an older adult who is
constipated? ✔Correct Answer-FRUIT (high fiber)
A patient has diareah and decreased skin turger and dark urine, nased on this data which of the
following would be the nursing diagnosis? ✔Correct Answer-deficient fluid volume
Which of the following nursing diagnosis are potentially appropriate for a patient with a new
ileostomy (diversion for the bowel) ✔Correct Answer-risk for skin deteriation, disturbed body
image
Which of the following techniques is appropriate when administering soap suds enema (SEE)
✔Correct Answer-administer 500-1000 ml of solution ( left side sims because bowel goes down
there)