NUR204 exam 2 Questions with 100%
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1. Which action should be taken when attempting to decrease falls in the
hospital setting?
a. Lower the height of the bed and the bottom two side rails before leaving the
room.
b. Ask patients on first encounter to use the bathroom and every 4 hours
thereafter.
c. Instruct patients to use the call light only if they think they need help getting
out of bed.
d. Encourage patients to not take any prescribed medicine that could cause
drowsiness or light headedness. Correct Answer: Answer: a
Keeping the bed in the lowest position and lowering the bottom side rails
decreases the chance of a fall. Hourly rounding for toileting is recommended to
improve patient safety. Patients should always use a call light to get up even if
they do not think they need it. Patients should take prescribed medications but
may need assistance with ambulation.
2. The nurse demonstrates proper use of a fire extinguisher by taking which
action first?
a. Sweep from side to side
,b. Pull the pin
c. Squeeze the handles together
d. Aim and approach the fire Correct Answer: Answer: b
The pin must be pulled to break the seal and activate the fire extinguisher.
When using a fire extinguisher, remembering the PASS acronym (i.e., pull, aim,
squeeze, and sweep) ensures proper technique.
A nurse is assessing a patient in restraints. The nurse observes correct use of
restraints by checking which of the following?
a. Restraint is tied in a secure knot.
b. Restraint is secured to the bedrail.
c. Restraint allows for 3 to 4 fingers width between restraint and patient's wrist.
d. Restraint is secured to the bedframe. Correct Answer: Answer: d
Restraints should be secured to a part of the bed that moves with the patient.
The bedframe allows for a secure area to attach. The restraint should always be
tied in a quick release knot that can be easily untied in an emergency. The
recommendation is for two finger widths of space between the restraint and the
patient's extremity.
4. What actions should be taken when caring for an 80-year-old postoperative
patient with a history of Parkinson's disease?
a. Ensure that all four side rails are elevated.
b. Instruct family that they cannot leave the room.
,c. Place wrists in soft restraints to protect invasive lines.
d. Include hourly rounding in the plan of care. Correct Answer: Answer: d
Hourly rounding prevents patient falls and addresses patient care needs. Four
side rails are considered a restraint. Restraints are used only if other measures to
keep the patient safe have been tried and failed. It is the nurse's responsibility to
care for the patient; families are not required to be with patients at all times.
5. The nurse is caring for a patient requiring parenteral anticoagulant therapy.
Which of the following actions should the nurse take to maximize patient safety?
(Select all that apply.)
a. Double-check order and dosage with another RN.
b. Administer medication using a smart IV infusion pump.
c. Administer heparin only through a central venous catheter.
d. Monitor glucose every 6 hours.
e. Assess and document IV site every 8 hours. Correct Answer: Answer: a, b
, Double-checking the order and dose with another RN can prevent errors. Using
an IV smart pump to administer anticoagulants increases correct dose
administration. Heparin can be administered through a peripheral line. Glucose
is not a focus of anticoagulant therapy. IV access requires more frequent
monitoring than every 8 hours.
. The nurse implements the necessary safety precautions in an environment for a
patient by doing which of the following? (Select all that apply.)
a. Place bed in lowest position with brakes locked.
b. Put both upper side rails up while patients are in bed.
c. Move personal belongings within reach.
d. Place bedside table between patient and the bathroom to use as a resting
area.
e. Ensure that all patients have bedside commode access. Correct Answer:
Answer: a, b, c
The safest bed position is lowest to the ground and secure (brakes intact) with
the upper two side rails elevated. Raising all four side rails is restrictive and
should not be used. Having personal belongings within reach minimizes patients
Correct Answers | Verified | Latest
Update Questions with 100% Correct
Answers
1. Which action should be taken when attempting to decrease falls in the
hospital setting?
a. Lower the height of the bed and the bottom two side rails before leaving the
room.
b. Ask patients on first encounter to use the bathroom and every 4 hours
thereafter.
c. Instruct patients to use the call light only if they think they need help getting
out of bed.
d. Encourage patients to not take any prescribed medicine that could cause
drowsiness or light headedness. Correct Answer: Answer: a
Keeping the bed in the lowest position and lowering the bottom side rails
decreases the chance of a fall. Hourly rounding for toileting is recommended to
improve patient safety. Patients should always use a call light to get up even if
they do not think they need it. Patients should take prescribed medications but
may need assistance with ambulation.
2. The nurse demonstrates proper use of a fire extinguisher by taking which
action first?
a. Sweep from side to side
,b. Pull the pin
c. Squeeze the handles together
d. Aim and approach the fire Correct Answer: Answer: b
The pin must be pulled to break the seal and activate the fire extinguisher.
When using a fire extinguisher, remembering the PASS acronym (i.e., pull, aim,
squeeze, and sweep) ensures proper technique.
A nurse is assessing a patient in restraints. The nurse observes correct use of
restraints by checking which of the following?
a. Restraint is tied in a secure knot.
b. Restraint is secured to the bedrail.
c. Restraint allows for 3 to 4 fingers width between restraint and patient's wrist.
d. Restraint is secured to the bedframe. Correct Answer: Answer: d
Restraints should be secured to a part of the bed that moves with the patient.
The bedframe allows for a secure area to attach. The restraint should always be
tied in a quick release knot that can be easily untied in an emergency. The
recommendation is for two finger widths of space between the restraint and the
patient's extremity.
4. What actions should be taken when caring for an 80-year-old postoperative
patient with a history of Parkinson's disease?
a. Ensure that all four side rails are elevated.
b. Instruct family that they cannot leave the room.
,c. Place wrists in soft restraints to protect invasive lines.
d. Include hourly rounding in the plan of care. Correct Answer: Answer: d
Hourly rounding prevents patient falls and addresses patient care needs. Four
side rails are considered a restraint. Restraints are used only if other measures to
keep the patient safe have been tried and failed. It is the nurse's responsibility to
care for the patient; families are not required to be with patients at all times.
5. The nurse is caring for a patient requiring parenteral anticoagulant therapy.
Which of the following actions should the nurse take to maximize patient safety?
(Select all that apply.)
a. Double-check order and dosage with another RN.
b. Administer medication using a smart IV infusion pump.
c. Administer heparin only through a central venous catheter.
d. Monitor glucose every 6 hours.
e. Assess and document IV site every 8 hours. Correct Answer: Answer: a, b
, Double-checking the order and dose with another RN can prevent errors. Using
an IV smart pump to administer anticoagulants increases correct dose
administration. Heparin can be administered through a peripheral line. Glucose
is not a focus of anticoagulant therapy. IV access requires more frequent
monitoring than every 8 hours.
. The nurse implements the necessary safety precautions in an environment for a
patient by doing which of the following? (Select all that apply.)
a. Place bed in lowest position with brakes locked.
b. Put both upper side rails up while patients are in bed.
c. Move personal belongings within reach.
d. Place bedside table between patient and the bathroom to use as a resting
area.
e. Ensure that all patients have bedside commode access. Correct Answer:
Answer: a, b, c
The safest bed position is lowest to the ground and secure (brakes intact) with
the upper two side rails elevated. Raising all four side rails is restrictive and
should not be used. Having personal belongings within reach minimizes patients
