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Question 1

1 pts

A community health nurse is teaching parents of preschoolers appropriate safety measures for children of this age group. Which of the following measures should the nurse emphasize?

Group of answer choices

Childproofing the house

Frequent handwashing

Fire safety

Gun safety

 

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Question 2

1 pts

A public health nurse is planning a safety campaign. Which of the following populations would benefit from fall prevention strategies based on their developmental stage? Select all that apply.

Group of answer choices

Newborns

Toddlers

School-age children

Adolescents

Adults

Older adults

 

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Question 3

1 pts

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the physician for an order for restraints. Which of the following are accurate guidelines for the use of restraints on clients? Select all that apply.

Group of answer choices

Restraints may be used to prevent a client from falling if the facility is short-staffed.

The client’s family must be involved in the decision and plan of care.

Alternatives to restraints and less restrictive interventions must have been implemented and failed.

The benefit gained from using a restraint must outweigh the known risks for that client.

A physician or licensed independent practitioner must reevaluate and assess the client every 48 hours.

The client’s vital signs must be assessed and the medical client must be visually observed every 4 hours.

 

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Question 4

1 pts

A nurse enters a client’s room and finds that the client has fallen on her way to the bathroom. Which of the following is the best nursing intervention for this client?

Group of answer choices

Briefly leave the client in order to call the primary physician to assess the client’s condition.

Assist the client back to bed and teach her about falls prevention measures.

Assess the client and document the incident and interventions in the client’s medical record.

Perform a head-to-toe assessment to determine whether an incident report is necessary.

 

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Question 5

1 pts

A client with impaired mobility following recent knee replacement is being discharged to her home with continuing care from a community health nurse. What client teaching regarding safety and falls prevention should the nurse share with this client?

Group of answer choices

Abstain from exercising until the knee is completely healed.

Keep home temperature at a moderate level to prevent dizziness.

Wear socks around the house to avoid catching a heel in a rug.

Stand up quickly from a sitting or lying position to allow blood to move to the head.

 

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Question 6

1 pts

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which of the following interventions will best preserve this client’s safety and could be used as an alternative to restraints?

Group of answer choices

Investigate the possibility of discontinuing his catheter.

Limit the resident’s fluid intake in order to reduce his urge to void.

Collaborate with the resident’s physician to have his diuretics discontinued.

Increase the resident’s physical activity to reduce evening restlessness.

 

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Question 7

1 pts

A physician has ordered restraints for an elderly client who is delirious from the pain medication she was administered. Which of the following is an appropriate guideline for utilizing restraints?

Group of answer choices

Chemical restraints should be tried before using physical restraints.

The restraints can be ordered by the nursing supervisor in emergency situations.

The client’s vital signs must be assessed every hour.

The client’s order for restraints must be renewed by the physician every 4 hours.

 

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Question 8

1 pts

A nurse is preparing to implement an order for the use of restraints to ensure a client’s safety. Which of the following statements accurately describes a letter represented in the R-E-S-T-R-A-I-N-T acronym?

Group of answer choices

Respond to the past history of the client (including previous falls) to determine the need for restraints.

Alert the physician and the client’s family if restraints are ordered by the client’s primary nurse.

Individualize the use of restraints and choose the most easily used device.

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

 

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Question 9

1 pts

A physician orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse’s most appropriate action when carrying out this order?

Group of answer choices

Apply restraints to the hands or wrists, never to the ankles.

Ensure that two fingers can be inserted between the restraint and the client’s extremity.

Use a quick-release knot to tie the restraint to the side rail.

Remove the restraint at least every 4 hours, or according to agency policy.

 

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Question 10

1 pts

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which of the following actions?

Group of answer choices

Place the client in a prone position to apply the restraint.

Remove the client’s upper body clothing and reapply it over the restraint.

Insert a fist between the restraint and the client to ensure that her breathing is not constricted.

Assess the client at least every 2 hours or according to facility policy, as required.

 

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Question 11

1 pts

The nurse caring for a 3 year-old client notices that he is attempting to pull at his surgical incision site. What would be the best type of restraint to prevent him from doing this?

Group of answer choices

Elbow restraint

Vest restraint

Extremity restraint

Mummy restraint

 

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Question 12

1 pts

Which of the following is a recommended guideline for applying an elbow restraint?

Group of answer choices

Choose the correct size of the device that allows for the least amount of mobility.

Spread an elbow restraint out flat, and place middle of elbow restraint behind the client’s elbow.

Make sure the restraint extends below the wrist and does not put pressure on the axilla.

Wrap restraint snugly around the client’s arm, making sure that a fist can easily fit under the restraint.

 

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Question 13

1 pts

A toddler has a foreign body lodged in her nasal sinus and the physician will attempt to remove it using forceps. What type of restraints is most appropriate in this situation?

Group of answer choices

Elbow restraint

Waist restraint

Extremity restraint

Mummy restraint

 

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Question 14

1 pts

A nurse is placing an infant in a mummy restraint to perform eye care. Which of the following is a recommended guideline for application of a mummy restraint?

Group of answer choices

Place the child on the blanket, with the edge of the blanket at or above neck level.

Position the child’s left arm alongside the body and pull the right side of the blanket over the shoulder and chest.

Leave the lower part of the blanket open and pull the sides of the blanket over the child’s body.

Secure the blanket under the child’s body on each side by tucking it in instead of using safety pins.

 

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Question 15

1 pts

A gerontologic nurse is assessing an older adult client’s risk for falls. Which of the following aspects of the client’s current health status should the nurse identify as increasing the client’s risk for falls? Select all that apply.

Group of answer choices

Recent changes have been made to the client’s medication regimen.

The client has recently moved to a new assisted living facility.

The client has recently been diagnosed with hypertension.

The client had knee replacement surgery 6 weeks ago.

An occupational therapist has begun working with the client.

 

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Question 16

1 pts

A registered nurse is overseeing the care of numerous residents in a care facility. Which of the following tasks can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Group of answer choices

Assessing a new resident’s risk for falls

Assessing the circulation of a resident in extremity restraints

Removing items that have been deemed a falls risk from a resident’s room

Helping a resident safely ambulate to the bathroom from her bed

Applying a waist restraint that has been ordered for a resident

 

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Question 17

1 pts

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse’s best action for reducing the client’s risk of falls?

Group of answer choices

Provide a bedside commode and ensure adequate lighting.

Obtain an order for insertion of an indwelling urinary catheter.

Limit the client’s fluid intake during the evening.

Accompany the client to the bathroom every 4 hours around the clock.

 

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Question 18

1 pts

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this patient’s care?

Group of answer choices

Impaired Bed Mobility Related to Muscle Wasting

Noncompliance Related to Mediation Regimen

Risk for Injury Related to Agitation

Chronic Confusion Related to Longstanding Alcohol Use

SCIENCE
HEALTH SCIENCE
NURSING
NURSING BS 3101

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