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NUR 3480 Final Exam Questions And Answers
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NUR 3480 Final Exam Questions AndAnswers
Safety/Falls - - correct answer ✅o Falls can cause life-threatening
injuries
o Haven fallen previously is an important indicator for a future fall
o Look in room for things that can contribute to fall risks.
o All four side rails up is a restraint if patient is confused.
o Include family members, sitters (usually not first resort), hourly
rounding, gait belts, communication
■ First priority when patient falls is to ASSESS patient
■ Exercise prevents fall risk by inc. balance and preventing
weakness
■ Stay arm length away from patient if you helped them get to the
bathroom
■ Consider assistive devices, IV pole, catheter
■ Use caution with bedside commodes: fall risk
○ High fall risk or confused pt.: remain by bedside until they are
done using the commode
,NUR 3480 Final Exam Questions And
Answers
Primary causes of falls - - correct answer ✅confusion, depression,
environment, meds
Fall interventions - - correct answer ✅follow hospital policy, lock
bed, bed low, communication (patient education), toileting plan,
observe, assess if patient needs bedside commode.
Call light, lighting in room, exercise, assistive devices/nurse, Do Not
leave patient in the bathroom if you took them there/arm length.
Restraints - - correct answer ✅o Always last resort
▪ Least restrictive first, can increase risk for falls, skin breakdown,
injury, aspiration can all occur when using restraints, RN
assessment only
▪ Turn and and check skin every 2 hours,
▪ Documentation, MD to evaluate within 24 hours
▪ Determine type of restraint for patient (hard/soft)
,NUR 3480 Final Exam Questions And
Answers
▪ Ex: Mitts, soft, Posey vest, or leather
■ Safety interventions for confused pt.:
● Restraints (soft)/all 4 bed rails up: need doctor order
■ Must inform family members if restraints needed and if pt. is at
risk for falls
Hygiene - - correct answer ✅● Initial assessment: must assess skin
of pt., especially if incontinent, to prevent skin breakdown and
infection
o Maintain privacy when cleaning
o Consider gender/cultural differences
o Do not wash over IV sites, central lines, wounds, etc
o Patients should have bath daily (Encourage patient to wash as
much for themselves), keep patient warm, keep water warm, do
not scrub skin-could damage skin tissue
, NUR 3480 Final Exam Questions And
Answers
-Oral/denture care; caution when considering shaving/nail cutting
(not recommended-bleeding risk)
■ Encourage the pt. to do as much as they can themselves
Activity - - correct answer ✅o Assess patient PRIOR to moving
o Need to consider if you need help: sliding board, wheelchair, lift,
gait belt
■ If pt. is able to perform all ADLs, then they are using effective
ROM
○ Active: with participation from pt.
○ Passive: w/out participation from pt
o Communicate with patient when moving
o Side rails should be up when turning patient, turn patient every 2
hours
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