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 ca...
NUR204 Exam 2 Questions and Answers
UPDATED 2024-2025
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.
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
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.
NUR204 Exam 2
,NUR204 Exam 2
c. Restraint allows for 3 to 4 fingers width between restraint and patient's wrist.
d. Restraint is secured to the bedframe.
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.
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.
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.
NUR204 Exam 2
,NUR204 Exam 2
. 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.
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 moving
about to get items. The bedside table has wheels and is not stable to use for resting.
It creates an obstacle for the patient to navigate on the way to the bathroom and
would be better placed on the opposite side of the bed from the bathroom. Some
patients are able to walk to the bathroom; therefore, they do not require a bedside
commode.
7. The nurse would understand the need for further safety education when a parent
makes which of the following statements?
a. "I secure my 8-month-old in a rear-facing car seat in the back seat."
b. "My 10-year-old is angry that I still make him use a booster seat and he is not
permitted to ride in the front seat."
c. "My 2-month-old sleeps the longest when I put him in his crib on his stomach."
d. "All of our household cleaners are stored in the upper cabinets in my home."
Answer: c
Infants should be placed on their backs to sleep to prevent sudden infant death
syndrome. The other statements all agree with safety recommendations and show
an understanding of correct behavior.
8. A patient is being discharged and several previous medications are being
discontinued. The patient asks the nurse what she should do with unused
medications. The nurse demonstrates knowledge of proper disposal of medications
by which of the following? (Select all that apply.)
a. Encouraging the patient to use a drug take-back location if available
NUR204 Exam 2
, NUR204 Exam 2
b. Telling the patient to check the label and, if approved, flush the medication
down the toilet
c. Encouraging the patient to donate the unused medication to a local hospital for
use
d. Teaching the patient to add coffee grounds to the medication, put in a sealed bag,
and dispose in the trash.
e. Checking to see whether the patient’s family members could benefit from the
medication.
Answer: a, b, d
Drug take-back locations are the recommended disposal method for unused and
expired medications. If a medication can be flushed down the toilet, this is the next
recommended way to discard medication. Since some may not be able to be flush,
they should be mixed with an undesirable substance, placed in a sealed bag, and
then disposed of. Medications are not meant to be shared; thus, they should not be
sent to a health care facility or given to a family member.
Which of the following interventions by the nurse addresses a National Patient
Safety Goal as indicated by The Joint Commission?
a. Take a picture of the patient upon admission to verify patient identity.
b. Answer patient call alarms in a timely manner.
c. Provide patients a permanent marker to label all of their medications.
d. Use hand sanitizer as the best option for hand hygiene.
Answer: b
One of the patient safety goals focuses on reducing harm associated with clinical
alarm systems. A nurse responding to a patient alarm in a timely manner indicates
that the alarm can be heard and the patient condition is being assessed. Patients
should be identified by scanning barcodes or comparing the patient's stated name
and birthdate to information on the patient's wristband or health record. Patients are
encouraged to leave medications in labeled bottles. Handwashing remains the most
effective hand hygiene technique.
The nurse is providing discharge instructions on ways to prevent falls at home.
Which of the following guidelines are helpful in preventing falls? (Select all that
apply.)
a. Always wear socks when walking to protect your feet when ambulating.
NUR204 Exam 2
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