Med surge practice exam 1

A couple caring for their aging parents are concerned about risk factors for falls. Which riskfactors are most likely to contribute to falls in the elderly?Select all that apply

• Inadequate lighting

• Multiple medications

• Doorway thresholds

• Cords covered by carpet

• Staircases with handrails

The nursing assistant of an 80 year old patient who demonstrates some confusion but noanxiety reveals that the patient is a fall risk because they continue to get out of bed despitefrequent reminders. The initial nursing intervention to prevent falls for this patient i

• Activate the bed alarm device on the bed

• Place the patient in a belt restrain

• Place one-on-one observation of the patient

• Apply wrist restraint

A nurse is evaluating a patient placed in soft, non-violent wrist restraints. Which of the followingshould the RN perform? Select all that apply

• Check peripheral pulses in restrained extremities

• Evaluate the patient’s need for toiletin

• Offer the patient fluids (if appropriate per orders

• Release both limbs at the same time to perform range of motion (ROM) exercis

• Inspect the skin under each restraint

Emergency restraints or seclusion may be implemented without a physician’s order under whichof the following conditions

• never

• When a written order will be obtained from the primary physician within 8 ho

• If a voluntary client wants to leave against medical advi

• When a minor child is out of control

You're patient is being transported to special procedures for a PICC line placement. The patientis in droplet precautions. What are your nursing actions to ensure proper transport of thepatient?

• Notify the receiving department and place goggles, gown, and mask on the patie

• Cancel transport and notify the physician for further orders.

• Place an N95 mask on the patient and notify the receiving departmen

• Notify the receiving department and place a surgical mask on the patient

You enter the patient’s room and find that they are on the floor next to the bed. They areunresponsive. You see urine on the floor, several loose pills on the ground, and the patientvomited. What is the initial nursing action

• Push an opioid reversal agent

• Check for a pulse and breathing

• Initiate CPR and Call for Help

• Push an opioid reversal agent

You are evaluating a cis-male client for complaints of urethral discharge s/p diagnosis ofgonorrhea with failed antibiotic treatment. Upon your assessment, you obtain a chaperone(another RN) and you both utilize the following type of precautions

• contact

• Standard

• airborne

• droplet

What is the most effective way to prevent hospital based infections?

• Identifying the infectious agent

• Hand hygiene practice

• Isolation precautions

• vaccinations

You're providing care to a patient with C. Diff. After removing the appropriate PPE, you wouldperform hand hygiene by

• Using soap and water only if hands are soiled but can use hand sanitiz

• Using hand sanitizer

• Using soap and water

• Using either hand sanitizer or soap and wate

A patient is diagnosed with methicillin-resistant staphylococcus aureus (MRSA) pneumonia.Which type of isolation precaution is most appropriate for this clien

• Droplet

• contact

• airborne

• standard