NUR 242 Exam #2 with complete solutions
2024/2025
While making rounds, the nurse finds a patient on the floor in the hallway. Which
action will the nurse do first?
-assess the patient for injury
-transfer the patient back to bed
-assist the patient to a wheelchair
-report the patient's condition to the physician - ANSWER- -assess the patient for
injury
Which action should the nurse take to prevent accidents?
-apply a restraint when the patient is in the wheelchair to keep them from falling
-determine the strength of the patient
-turn all the lights off in the room so the patient can sleep
-provide a cane for walking if the patient is weak - ANSWER- -determine the
strength of the patient
When caring for a patient who is able to get out of bed independently and safely,
the nurse will
-leave one side rail at the foot of the bed up
-leave one side rail up when there are only two side rails on the bed
-leave both side rails up in a two side rail bed
-leave all four side rails up for all patients at all times - ANSWER- -leave one side
rail up when there are only two side rails on the bed
The nurse is monitoring for Never Events. Which finding indicates the nurse will
report a Never Event?
-a sponge is left in the patient's incision
-pulmonary embolism after lung surgery
-no blood incompatibility occurs with a blood transfusion
, -development of stage II pressure ulcer - ANSWER- -a sponge is left in the
patient's incision
The nurse discovers a patient on the floor. The patient states that he fell out of
bed. The nurse assesses the patient and finds no apparent changes in the
previous assessment. The nurse assists the patient back to bed. Which action
should the nurse take next?
-notify the health care provider
-do nothing, no harm has occurred
-notify the family
-complete an incident report - ANSWER- -notify the health care provider
The nurse is teaching a group of older adults at an assisted living facility about
age related physiological changes affecting safety. Which question would be
most important for the nurse to ask this group?
-Are you able to taste spices like before?
-Are you able to hear the tornado sirens in your area?
-Are you able to read the newspaper?
-Are you able to open a jar of pickles? - ANSWER- -Are you able to hear the
tornado sirens in your area?
The nurse is trying to use diversion rather than restrain a patient. Which finding
will cause the nurse to determine the diversion is working?
-the patient apologizes for being "such a bother"
-the patient folds three washcloths over and over
-the patient gets restless when the sitter leaves for lunch
-the patient continues to get up from the chair at the nurse's station - ANSWER- -
the patient folds three washcloths over and over
The nurse is caring for a patient who suddenly becomes confused and tries to
remove a wound dressing. Which priority action will the nurse take?
-call the healthcare provider for a restraint order
-gather restraint supplies
-remove the dressing and leave wound open to air
-assess the patient - ANSWER- -assess the patient
The nurse is providing patient care for a post surgical patient. Which action
indicates the nurse is following the National Patient Safety Goals?
-obtains vital signs prior to sending a patient to surgery
-identifies patient with one identifier prior to transporting to the radiology
department
2024/2025
While making rounds, the nurse finds a patient on the floor in the hallway. Which
action will the nurse do first?
-assess the patient for injury
-transfer the patient back to bed
-assist the patient to a wheelchair
-report the patient's condition to the physician - ANSWER- -assess the patient for
injury
Which action should the nurse take to prevent accidents?
-apply a restraint when the patient is in the wheelchair to keep them from falling
-determine the strength of the patient
-turn all the lights off in the room so the patient can sleep
-provide a cane for walking if the patient is weak - ANSWER- -determine the
strength of the patient
When caring for a patient who is able to get out of bed independently and safely,
the nurse will
-leave one side rail at the foot of the bed up
-leave one side rail up when there are only two side rails on the bed
-leave both side rails up in a two side rail bed
-leave all four side rails up for all patients at all times - ANSWER- -leave one side
rail up when there are only two side rails on the bed
The nurse is monitoring for Never Events. Which finding indicates the nurse will
report a Never Event?
-a sponge is left in the patient's incision
-pulmonary embolism after lung surgery
-no blood incompatibility occurs with a blood transfusion
, -development of stage II pressure ulcer - ANSWER- -a sponge is left in the
patient's incision
The nurse discovers a patient on the floor. The patient states that he fell out of
bed. The nurse assesses the patient and finds no apparent changes in the
previous assessment. The nurse assists the patient back to bed. Which action
should the nurse take next?
-notify the health care provider
-do nothing, no harm has occurred
-notify the family
-complete an incident report - ANSWER- -notify the health care provider
The nurse is teaching a group of older adults at an assisted living facility about
age related physiological changes affecting safety. Which question would be
most important for the nurse to ask this group?
-Are you able to taste spices like before?
-Are you able to hear the tornado sirens in your area?
-Are you able to read the newspaper?
-Are you able to open a jar of pickles? - ANSWER- -Are you able to hear the
tornado sirens in your area?
The nurse is trying to use diversion rather than restrain a patient. Which finding
will cause the nurse to determine the diversion is working?
-the patient apologizes for being "such a bother"
-the patient folds three washcloths over and over
-the patient gets restless when the sitter leaves for lunch
-the patient continues to get up from the chair at the nurse's station - ANSWER- -
the patient folds three washcloths over and over
The nurse is caring for a patient who suddenly becomes confused and tries to
remove a wound dressing. Which priority action will the nurse take?
-call the healthcare provider for a restraint order
-gather restraint supplies
-remove the dressing and leave wound open to air
-assess the patient - ANSWER- -assess the patient
The nurse is providing patient care for a post surgical patient. Which action
indicates the nurse is following the National Patient Safety Goals?
-obtains vital signs prior to sending a patient to surgery
-identifies patient with one identifier prior to transporting to the radiology
department
