chapter 13

1. A nurse is caring for a female patient who has been hospitalized for a right-side dcerebrovascular accident (CVA). The patient is impulsive and confused. She has weakness on the left side of her body and requires assistance when ambulating. What is the nurse’s highest priority when caring for this patient?

A nurse manager is working on methods to decrease patient falls on the nursing unit.Which nursing action would lead to decreased falls?

A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions.The nursing instructor would intervene if the student nurse is observed doing what?

A nurse is admitting a 65-year-old patient with a diagnosis of transient ischemic attack. The patient is alert and responds appropriately to questions. Based on this information, what type of intervention should the nurse take to maintain patient safety?

A fire breaks out on the nursing unit and the fire doors close. A family member tries to open the doors. What is the best response by the nurse based on the RACE protocol?

A nursing student is reviewing the PASS acronym. Which action is consistent with following this protocol?

A charge nurse supervises an unlicensed assistive personnel(UAP)while providing care to a patient at risk for falls. The patient repeatedly attempts to get out of bed without assistance. The charge nurse intervenes when observing which action by the UAP?

8.A nurse is completing documentation on a chart outside the patient’s room and hears a loud thud coming from the room. What is the priority nursing action?

When caring for a patient with bilateral wrist restraints,a nurse can delegate which of the following to a certified nursing assistant (CNA)?

A nurse is working on a nursing unit and moving a patient up in the bed.Which observation by the nurse manager warrants immediate intervention?

A nurse is extinguishing a fire that has broken out in the work place.Which is the first step the nurse should take?

A nurse is monitoring a chemotherapy patient and finds a moderate amount off fluid on the floor in the patient’s room. The nurse is not sure about what the fluid is. What is the priority nursing action?

A student nurse encounters an unresponsive patient in a waiting room.The patient is not breathing and has no pulse or respirations. What is the first step the student nurse should take?

A member of the hospital maintenance staff is mopping the floor when patients begin to complain about watery eyes and irritated throats. Which priority action should the nurse take?

A patient who is a fall risk is sitting in the chair with the call bell in reach after being assisted by the certified nursing assistant (CNA). The patient’s bed alarm continues to go off. What is the first action that the nurse should take upon going into the patient’s room?

Which of the following items increase a patient’s risk for falling,according to the Morse Fall Scale?Select all that apply.

A nurse is caring for a patient who has been placed in restraints.Which statements made to the patient by the nurse indicate an understanding of following restraint guidelines of the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission? Select all that apply.

A nurse is assessing a patient using the Morse Fall Scale and documents a modified risk levelII.Which findings best support this assessment? Select all that apply.

A nurse is monitoring a patient who continually attempts to scratch an area of the body. Which priority actions should the nurse take to minimize this patient action? Select all that apply.

A nurse is monitoring a patient who has received implanted radiation therapy.What are the best nursing actions related to taking care of this type of patient?

A group of student nurses are reviewing what to do should a mass casualty event (MCE) occur while they are in the clinical environment. Which actions should the student nurses be expected to perform? Select all that apply.

A nurse is working on a medical unit where restraint shave been routinely used on patient stop even them from injury. For which situations would the use of restraints be indicated? Select all that apply.

A nurse is documenting the Morse Fall Scale for a patient who is admitted for urinary sepsis, has no other comorbidities, uses a walker, is receiving IV antibiotics, has a weak gait, and is oriented to time and place. What information should the nurse document? Select all that apply.

A nurse applie swrist restraints to a patient.Which actions indicate appropriate technique?Select all that apply.

CVA Fall Precautions

Fall Reduction Strategies

Student Nurse Observation

RACE Protocol

PASS Acronym

Noise Incident Response

Use of Restraints

CMS Guidelines

Morse Fall Scale

CPR for Unresponsive Patients

Chemical Exposure Response

Alarm Response for Fall Patients

Radiation Therapy Safety

Monitoring Scratching Patients

Mass Casualty Events (MCE)

Restraint Documentation

Applying Restraints

Environmental Modifications

Regular Assessments

Patient Safety Protocols

Intervention in Emergencies

Emergency Response Team

Patient-Assistance Delegation

Behavior Monitoring