NUR 204 EXAM 1: CRAVEN
NUR 204 EXAM 1: CRAVEN STUDY GUIDE
QUESTIONS AND ANSWERS WITH VERIFIED
SOLUTIONS 2024
17. Fall prevention is done on multiple levels by nurses in the hospital. Which of the
following would not be an example of fall prevention done by nursing?
a. Reminding the patient to use the call light for assistance when getting out of bed
b. Placing the bed mattress on the floor to prevent injury
c. Developing an organizational policy for hourly rounding schedules to be performed on
each unit to monitor patient needs and comfort level
d. Applying restraints to patients at risk for falls -Correct Answer ✔ANSWER: D
RATIONALE: Restraint application is not an appropriate method for reducing fall risk
and may cause more injury to the patient. Injury control interventions are centered at
three primary levels: the individual level (e.g., providing education about safety hazards
and prevention strategies); the design phase, using engineering and environmental
controls (active or passive safety features that can prevent injury from product or
equipment use); and the regulatory level, creating, monitoring, and enforcing regulations
to ensure safe products and environments. Reminding the patient to use the call light
would be individual education, placing the mattress on the floor would be environmental
or design prevention, and developing an organizational policy for monitoring would be at
the regulatory level of injury prevention.
17. The caregiver of a child asks about car safety for a 1-year-old child. What principle
will guide your answer?
a. Keep children facing the rear of the vehicle for as long as possible.
b. Children should be taken out of car seats as soon as possible.
c. The safest place for a child is in the front seat of the vehicle.
d. Children should use adult seat belts as soon as possible. -Correct Answer
✔ANSWER: A
RATIONALE: Children should be kept rear-facing in the vehicle as long as possible. The
back seat of the car is the safest place for children. Children should be kept in car seats
or booster seats as long as possible, within the weight and height limits of the seat.
Adult seat belts should only be used when the child outgrows the car or booster seat.
17. Older adults may be at increased risk of injury related to physiologic factors. Which
of the following are relevant risk factors unique to this population? SATA
a. Decrease in sensory-perceptual function and cognitive judgment
b. Alcohol impairment
c. Impaired thermoregulation
NUR 204 EXAM 1: CRAVEN
,NUR 204 EXAM 1: CRAVEN
d. Medication side effects
e. Development of osteoporosis -Correct Answer ✔ANSWER: A,C, D
RATIONALE: Advancing age entails loss in physical function and usually in acuity of
sensory-perceptual function (e.g., impaired vision). Older adults may have impaired
eyesight and hearing and decreased proprioception to maintain balance and sensitivity
to touch. The ability to thermoregulate may become impaired; older adults are at higher
risk than younger adults for hypothermia and heat stroke. Reflex responses slow, and
the musculoskeletal system can lose flexibility and strength. Various conditions, such as
osteoporosis, arthritis, or heart failure, can limit the ability to endure sustained physical
activity. Medications taken to control conditions such as high blood pressure or
Parkinson disease may result in orthostatic hypotension and increase the potential for
falling. Alcohol impairment is not unique to older adults.
17. Nurses should be aware of various safety hazards in the workplace. Which of the
following present safety hazards to nurses? SATA
a. Cleaning solution spill
b. Chemotherapy administration
c. Needlestick injury
d. Assisting with patient mobility or transfers
e. Patient call systems -Correct Answer ✔ANSWER: A, B, C, D
RATIONALE: These safety hazards are relevant to nursing work environments. Other
occupational hazards may include noise, hazardous dusts (e.g., asbestos, lead, coal)
and chemicals, heights, dangerous machines, biologically infectious agents, and
violence. Other dangers result when employers or workers do not follow safety
precautions, such as wearing protective gear and following safe work practices. Patient
call systems do not pose a risk to staff; in fact, they may alert staff to urgent needs that
create safety hazards for patients.
17. An error occurs as the result of the lack of a double-check process on dosing of a
high-risk opiate pain medication. The patient becomes oversedated, necessitating
reversal of the opioids in order to regain a regular respiratory pattern. Which of the
following should the nurse do to document the incident? SATA
a. Describe factors that led up to the incident
b. Document patient assessment findings following the error
c. Chart in the patient's record the contributing factors
d. Include interventions needed to reverse oversedation in incident report
e. Document your personal dissatisfaction with the response from pharmacy about the
incident -Correct Answer ✔ANSWER: A, B, D
RATIONALE: Documentation of an error in an incident report should completely
describe all aspects of the event that occurred. Specifically, the report should include
the accident, patient assessment, and interventions provided for the patient. The report
NUR 204 EXAM 1: CRAVEN
,NUR 204 EXAM 1: CRAVEN
is used for internal review to improve the system to prevent similar errors and cannot be
subpoenaed by a court of law. This document remains confidential and is not part of the
patient's medical record; thus, the incident should not be detailed in the nursing notes or
other areas of the patient chart. Although professional judgment about things such as
contributing factors should be included, personal opinions about the situation should
not.
17. A nurse is providing discharge education for a postoperative patient who will be
leaving the hospital with a urinary catheter. What statement reflects appropriate
environmental safety education for this patient?
a. "Be aware that you are at risk for falling because the catheter tubing hangs by your
feet and is a tripping hazard."
b. "Your pain medications may cause side effects including drowsiness, so be sure not
to drive while you are taking them."
c. "Because of your incisions, you should be careful to not lift anything heavier than 10
lb."
d. "Change positions slowly to avoid dizziness." -Correct Answer ✔ANSWER: A
RATIONALE: Environmental safety hazards include patient care devices such as
catheters, surgical drains, or sequential compression devices. All other statements are
appropriate surgical discharge education but are not related to environmental safety.
17. A nurse is assessing a patient for safety upon discharge following a severe stroke.
Which of the following systems would be a priority for this patient's safety? SATA
a. Neurologic system
b. Cardiovascular system
c. Skin integrity
d. Musculoskeletal system
e. Respiratory system -Correct Answer ✔ANSWER: A, D, E
RATIONALE: For a patient managing deficits following a stroke, neurologic and
musculoskeletal system assessments would be a priority. Cardiovascular assessment is
not indicated because the cardiovascular capacity is not directly impacted by this
diagnosis. Skin assessment may provide important clues to the patient's history of
accidents or injuries but would not indicate new risk following a stroke. Respiratory
assessment is needed to ensure that the patient's breathing has not been impacted by
the stroke and to assess for choking or aspiration that may occur due to the stroke.
17. A nurse is evaluating outcome criteria for a patient following a stroke who is at risk
for aspiration. Which of the following would be appropriate goals for this patient? SATA
a. The patient will tuck chin for more effective swallow when drinking thin liquids.
b. The patient will avoid drinking liquids related to increased risk for aspiration.
c. The patient will have no signs or symptoms of aspiration (e.g., coughing).
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, NUR 204 EXAM 1: CRAVEN
d. The patient will place food on right side to avoid vision cut. -Correct Answer
✔ANSWER: A, C
RATIONALE: Appropriate goals for this stroke patient are to identify high-risk settings
(e.g., drinking thin liquids) and to demonstrate appropriate safety habits (chin tuck).
Avoiding drinking liquids is not appropriate at this stage. Compensation for a vision cut
is not related to risk for aspiration.
17. Restraints should be used for patient safety in which of the following situations?
SATA
a. The patient is attempting to remove mechanical ventilator tubing.
b. The patient is at risk for falling due to impaired neurologic status.
c. The patient is confused, is impulsive, and wants to leave the hospital unit.
d. The patient is combative with staff members.
e. The patient is picking at his oxygen tubing but is easily redirected. -Correct Answer
✔ANSWER: A, D
RATIONALE: Restraints are only clinically justified in selected instances to prevent
irreparable harm associated with pulling out therapeutic devices or when endangering
self or others. Risk for falls does not indicate restraint use because restraints have not
been shown to reduce fall or injury rates and may actually increase incidence of
unintended negative consequences. Impulsive behavior and confusion are not
indicators for restraints because restraints may increase agitation and injury. Patients
who are easily redirected should be managed without restraints as long as possible.
Redirection can be an effective alternative therapy to restraints.
17. In the event of a fire, what is the most important thing that a nurse needs to do?
a. Give patients wet washcloths to breathe through to reduce smoke inhalation
b. Close windows and doors and turn off oxygen
c. Determine which patients are in immediate danger
d. Evacuate bedridden patients -Correct Answer ✔ANSWER: C
RATIONALE: Determining which patients are in immediate danger is the priority for
nurses in case of a fire (assessment of the situation). Giving patients wet washcloths,
closing windows, and evacuating patients are all interventions that should be done once
assessment of risk is complete.
17. A conscious patient's respiratory function is currently being supported by a
mechanical ventilator. Although the patient has been sedated to facilitate the process,
blood pressure and heart rate still remain slightly elevated. What is the expected
outcome on the patient's well-being of having the nurse sit and hold the patient's hand
until a family member comes to spend the night?
a. The nurse's presence will distract the patient until the family member arrives.
NUR 204 EXAM 1: CRAVEN
