wayground logo

Free Printable Worksheets

Font size

S
M
L
XL
Worksheets

FUNDAMENTALS End Chapter Exam 1

Total questions: 79

Worksheet time: 3hrs 38mins

Name
Class
Date
1.

Which of the following data sets are examples of subjective data?

a)

Heart rate of 22 breaths/min and chest congestion

b)

Lung sounds revealing crackles and use of intercostal muscles to breathe

c)

Patient statement, “It’s hard for me to get a breath”

d)

Slumped posture and previous respiratory rate of 16 breaths/min

e)

Patient report of sore throat and hoarseness

2.

The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?

a)

Orientation

b)

Working phase

c)

Data interpretation

d)

Termination

3.

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:

a)

Reflection

b)

Clinical inference

c)

Cue

d)

Validation

4.

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?

a)

Current medications

b)

Patient expectations of planned surgery

c)

Review of patient’s family support system

d)

History of allergies

e)

Patient’s explanation for what might be the cause of symptoms that require surgery

5.

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time?

a)

Recognize normal changes associated with aging

b)

Avoid direct eye contact

c)

Lean forward and smile as you pose questions

d)

Allow for pauses as patient tells his story

e)

Use the list of questions from the clinic assessment form to complete all data

6.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment to the abdomen, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?

a)

Incorrect clustering of data

b)

Wrong diagnosis

c)

Condition is a collaborative problem

d)

Premature ending assessment

7.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly

a)

Offer frequent skin care because of Impaired Skin Integrity

b)

Risk for Infection

c)

Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion

d)

Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea

e)

Lack of Knowledge related to laser surgery

8.

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of:

a)

Collaborative data set

b)

Diagnostic label

c)

Related factors

d)

Data cluster

e)

Validated data set

9.

A nurse reviews data gathered regarding a patient’s response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following?

a)

Data collection

b)

Data clustering

c)

Data interpretation

d)

Making a diagnostic statement

e)

Outcome setting

10.

Setting priorities for a patient’s nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care?

a)

Priority setting establishes a preferential order for nursing interventions

b)

In most cases wellness problems take priority over problem-focused problems

c)

Recognition of symptom patterns helps in understanding when to plan interventions

d)

Longer-term chronic needs require priority over short-term problems

e)

Priority setting involves creating a list of care tasks

11.

Which intervention is a dependent intervention?

a)

Providing hand-off report at change of shift

b)

Enhancing the patient’s sleep hygiene

c)

Administering IV fluids

d)

Taking vital signs

12.

Which factors in a nurse’s unit environment will affect the ability to set priorities?

a)

Policy for conducting hourly rounds

b)

Staffing level

c)

Interruption by staff nurse colleague

d)

Type of hospital unit

e)

Competency of assistive personnel (AP)

13.

Which of the following outcomes is appropriate for a pt with a nursing diagnosis of Risk for Impaired Skin Integrity?

a)

Patient will be turned every two hours within 24 hours

b)

Patient will have normal formed stool within 48 hours

c)

Patient’s ability to turn self in bed improves

d)

Erythema of skin will be mild to none within 48 hours

14.

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse?

a)

The nurse directs the AP to obtain a set of vital signs on the patient returning from the diagnostic procedure

b)

The nurse directs the AP to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient

c)

The nurse directs the AP to set up meal trays for patients

d)

The nurse directs the AP to gather a history from the newly admitted patient about his medications

e)

The nurse directs the AP to assist one of the stable patients to sit up in a chair for his meal

15.

Which of these interventions is an indirect care measure?

a)

Irrigation of nasogastric tube

b)

Changing of transparent dressing

c)

Instructing patient to report tenderness at IV site

d)

Report of the amount of fluid aspirated

16.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

a)

Knowing the source of the guideline

b)

Reviewing the evidence used to develop the guideline

c)

Individualizing how to apply the clinical guideline for a patient

d)

Explaining to a patient the purpose of the guideline

17.

The nurse is visiting a patient who lives alone at home. While talking with the patient’s family caregiver, the nurse learns that the patient has been missing doses of medications. The patient currently self-medicates. The nurse wants to perform interventions to improve the patient’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to help the patient improve adherence?

a)

Reviewing the family caregiver’s understanding of purpose of medications

b)

Determining the value the patient places on taking medications

c)

Reviewing the number of medications and time each is to be taken

d)

Determining patient’s perceptions of consequences associated with missing specific medicines

e)

Reviewing the therapeutic actions of the medications

18.

The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the wound and ostomy care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions?

a)

The application of the skin barrier is a dependent care measure

b)

The call to the wound and ostomy care nurse specialist is an indirect care measure

c)

The cleansing of the skin is a direct care measure

d)

The application of the skin barrier is an instrumental activity of daily living

e)

Inspecting the skin is a direct care activity

19.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure?

a)

Checks scientific literature or policy and procedure

b)

Determines whether additional assistance is needed

c)

Collects all necessary equipment

d)

Delegates the procedure to a more experienced nurse

e)

Considers all possible consequences of the procedure

20.

A nurse is conferring with another nurse about the care of a patient with a Stage 2 pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following?

a)

Allows nurses to act more quickly and appropriately

b)

Sets a level of clinical excellence for practice

c)

Eliminates the need to create an individualized care plan for the patient

d)

Incorporates evidence-based interventions for stage II pressure injury

e)

Provides for access to patient care information within the electronic health record

21.

Which of the following is an evaluative measure?

a)

Asking patient to breathe deeply during auscultation

b)

Counting respirations per minute

c)

Asking the patient to describe how his breathing feels

d)

Starting the intravenous infusion

e)

Auscultating lung sounds

22.

Which of the following is a subjective evaluative measure?

a)

Counting respirations per minute

b)

Asking the patient to describe how his breathing feels

c)

Observing breathing pattern

d)

Auscultating lung sounds

e)

Having the patient explain purpose of the IV infusion

23.

Which of the following statements correctly describes the evaluation process?

a)

Evaluation involves reflection on the approach to care

b)

Evaluation involves determination of the completion of a nursing intervention

c)

Evaluation involves making clinical decisions

d)

Evaluation requires the use of assessment skills

e)

Evaluation is performed only when a patient’s condition changes

24.

A nurse in a community health clinic has been caring for a young female teenager with Type 1 diabetes mellitus for several months. The expected outcome for this patient is to achieve self-management of insulin administration by discharge. Identify appropriate evaluative measures for self-management for this patient.

a)

Quality of life

b)

Patient satisfaction

c)

Clinic follow-up visits

d)

Adherence to self-administration of insulin

e)

Description of side effects of medications

25.

Which of the activities below reflect the nurse’s ability to perform patient evaluation?

a)

Comparing patient response with previous response

b)

Examining results of clinical data

c)

Recognizing error

d)

Self-reflection

e)

Checking medical record for when IV was inserted

26.

What critical thinking indicators reflect the nurse’s ability to perform evaluation?

a)

Checking the summary notes

b)

Asking the leaving RN about the patient’s condition

c)

Assigning assistive personnel to measure intake and output

d)

Comparing current outcomes with those set for the patient’s goals

e)

Reflecting on patient’s progress

27.

A nurse enters a patient’s room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient’s expectations of care. Which of the following is appropriate for evaluating a patient’s expectations of care?

a)

On a scale of 0 to 10 rate your level of nausea

b)

The nurse weighs the patient

c)

The nurse asks, “Do you believe that you received the information you needed to follow your diet?”

d)

The nurse states, “Tell me four different foods included in your diet.”

28.

. A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the patient teaching?

a)

“The organism is usually transmitted through the fecal-oral route.”

b)

“Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer.”

c)

“Everyone coming into the room must wear a gown and gloves.”

d)

“While I am in Contact Precautions, I cannot leave the room.”

e)

“C. difficile dies quickly once outside the body.”

29.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient?

a)

Reverse isolation

b)

Droplet Precautions

c)

Standard Precautions

d)

Contact Precautions

30.

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but the nurse recognizes that this is a normal response to isolation. Which is the nurse’s best intervention?

a)

Provide a dark, quiet room to calm the patient

b)

Reduce the level of precautions to keep the patient from becoming angry

c)

Explain the reasons for isolation procedures and provide meaningful stimulation

d)

Limit family and other caregiver visits to reduce the risk of spreading the infection

31.

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster?

a)

Disposable gown

b)

N95 respirator mask

c)

Face shield or goggles

d)

Disposable mask

e)

Gloves

32.

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses’ part would contribute to reducing health care–acquired infections?

a)

Teaching correct hand washing to assigned patients

b)

Using correct procedures in starting and caring for an intravenous infusion

c)

Providing perineal care to a patient with an indwelling urinary catheter

d)

Isolating a patient on antibiotics who has been having loose stool for 24 hours

e)

Decreasing a patient’s environmental stimuli to decrease nausea

33.

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis?

a)

The front and sides of the sterile gown are considered sterile from the waist up

b)

Keep the sterile field in view at all times

c)

Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated

d)

Only health care personnel within the sterile field must wear personal protective equipment

e)

After cleansing the hands with antiseptic rub, apply clean disposable gloves

34.

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse’s best response?

a)

There is more than one organism in the wound that is causing the infection

b)

The antibiotics the patient has received are not strong enough to kill the organism

c)

to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism

d)

The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively

e)

There are no longer any antibiotic options available to treat the patient’s infection

35.

Which of these statements are true regarding disinfection and cleaning?

a)

Proper cleaning requires mechanical removal of all soil from an object or area

b)

Routine environmental cleaning is an example of medical asepsis

c)

When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound

d)

Cleaning in a direction from the least to the most contaminated area helps reduce infections

e)

Disinfecting and sterilizing medical devices and equipment involve the same procedures

36.

The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse?

a)

Vesicular breath sounds in the lung bases

b)

Temperature 38.5o C (101.4o F)

c)

Incision pain rating of 6 out of 10

d)

Blood glucose of 164 mg/dL

37.

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements?

a)

Usual range of circadian rhythm measurements

b)

Sustained fever pattern

c)

Intermittent fever pattern

d)

Resolving fever pattern

38.

Which of the following patients are at most risk for tachypnea?

a)

Patient just admitted with four rib fractures

b)

Woman who is 9 months pregnant

c)

A patient admitted with hypothermia

d)

Postoperative patient waking from general anesthesia

e)

Three-pack–per-day smoker with pneumonia

39.

During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information?

a)

Notify the health care provider immediately

b)

Repeat the measurements on both arms using a stethoscope

c)

Ask the patient whether she has taken her blood pressure medications recently

d)

Obtain blood pressure measurements on lower extremities

e)

Review the patient’s record for her baseline vital signs

40.

A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/72. He immediately repeated the measurement, and the value was 158/80. His normal BP value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/72?

a)

Cuff too small on the device

b)

Arm positioned above heart level

c)

Slow inflation of the cuff by the machine

d)

Patient did not remove his long-sleeved shirt

e)

Insufficient time between measurements

41.

A patient with heart failure is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions?

a)

Lower the head of the bed and return the patient to the supine position

b)

Obtain vital signs

c)

Encourage the patient to try to sit on the side of the bed and then stand

d)

Allow the patient to rest for 20 to 30 minutes

e)

Raise the head of the bed again and obtain blood pressure readings

42.

A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient?

a)

The patient keeps the cane on the left side of the body

b)

The patient slightly leans to one side while walking

c)

The patient keeps two points of support on the floor at all times

d)

After the patient places the cane forward, the patient then moves the right leg forward to the cane

e)

The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step

43.

A patient comes to an urgent care clinic with reports of pain in the right lower calf and ankle after participating in a 5K run. Which of the following assessment questions will determine the effects exercise has had on this patient?

a)

Tell me specifically when your pain began

b)

Describe for me the pain you are having

c)

In what way has your daily activity changed since you noticed your pain?

d)

How long have you been having the pain?

44.

The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?

a)

Increase the patient’s risk for falls and injuries

b)

Result in less stress on the patient’s joints

c)

Decrease the amount of work required for patient movement

d)

Allow for mobility in spite of the aging effects on the patient’s joints

45.

Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher?

a)

The patient is 167.6 cm (5 feet 6 inches) and weighs 54.5 kg (120 lb)

b)

The patient speaks and understands English

c)

The patient is returning to the unit from the recovery room after a procedure requiring conscious sedation

d)

The patient has a history of being able to stand independently

e)

The patient received analgesia for pain 30 minutes ago

46.

A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest?

a)

Move more and sit less throughout the day

b)

Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity

c)

Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity

d)

Walk at a vigorous pace with wife at least 150 minutes over five days a week

e)

Focus on balance training

47.

Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker?

a)

A walker is useful for patients who have impaired balance

b)

The patient uses a walker by pushing the device forward

c)

Leaning over the walker improves the patient’s balance

d)

Walkers should not be used on stairs

e)

If the patient has difficulty advancing the walker, a walker with wheels is an option

48.

A patient has been on bed rest for over 5 days. Which of these findings during the nurse’s assessment may indicate a complication of immobility?

a)

Decreased peristalsis

b)

Decreased heart rate

c)

Increased blood pressure

d)

Increased urinary output

49.

The effects of immobility on the cardiac system include which of the following?

a)

Thrombus formation

b)

Increased cardiac workload

c)

Weak peripheral pulses

d)

Irregular heartbeat

e)

Orthostatic hypotension

50.

A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures are appropriate for this patient to prevent complications of bed rest?

a)

Administer IV analgesic as ordered

b)

Have patient perform incentive spirometry

c)

Support patient in active assisted ROM exercises of upper extremities

d)

Provide patient a low-calorie diet

e)

Apply SCDs to legs

51.

An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess?

a)

Patient’s usual exercise pattern at home

b)

Time and date of the patient’s last bowel movement

c)

Pre-admission activity tolerance

d)

Baseline heart rate and blood pressure

e)

Patient’s home living situation

52.

A nurse is helping a patient perform active assisted ROM in the right elbow. Which statement describes the correct technique?

a)

Support elbow by holding distal part of extremity

b)

Grasp joint with fingers to provide support

c)

Have patient move joint independently

d)

Perform the exercise three times during the session, and gradually build up to more

53.

Which assessment data support a pulmonary issue related to immobility?

a)

Oxygen saturation of 89%

b)

Irregular radial pulse

c)

Diminished breath sounds in bilateral bases of lungs

d)

Blood pressure 132/84 mm Hg

e)

Respiratory rate of 26

54.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration?

a)

Modified left lateral recumbent position

b)

Semi-Fowler’s position with head to side

c)

Trendelenburg position

d)

Supine position

e)

Prone position

55.

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection?

a)

Cut nails frequently

b)

Assess skin for redness, abrasions, and open areas daily

c)

Soak feet in water at least 10 minutes before nail care

d)

Apply lotion to feet daily

e)

Clean between toes after bathing

56.

Which of the following factors directly impairs salivary gland secretion?

a)

Use of cough drops

b)

Immunosuppression

c)

Radiation therapy

d)

Dehydration

e)

Presence of oral airway

57.

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems that will require thorough bathing and skin care?

a)

A 44-year-old female patient who has had removal of a breast lesion and is in pain and unwilling to ambulate postoperatively

b)

A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration

c)

A 60-year-old female patient who experienced a stroke with right sided paralysis and has an orthopedic brace applied to the left leg

d)

A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and stool

58.

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure?

a)

Oxygen saturation

b)

Heart rate

c)

Respirations

d)

Gag reflex

e)

Response to painful stimulus

59.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care:

a)

Use fluoride toothpaste

b)

Brush teeth 4 times a day

c)

Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients

d)

Use a soft toothbrush for oral care

e)

Avoid cleaning the gums and tongue

60.

While planning morning care, which of the following patients would have the highest priority to receive a bath first?

a)

A patient who just returned to the nursing unit from a diagnostic test

b)

A patient with a fever who just finished a dose of intravenous antibiotics.

c)

A patient who is experiencing frequent incontinent diarrheal stools and urine

d)

A patient who has been awake all night because of pain 8/10

61.

The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who had a stroke. Which intervention(s) would be appropriate for the assistive personnel to accomplish during the bath?

a)

Checking distal pulses

b)

Providing range-of-motion (ROM) exercises to extremities

c)

Determining type of treatment for Stage 1 pressure injury

d)

Changing the dressing over an intravenous site

e)

Providing special skin care as indicated by nurse

62.

The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel (AP). What cultural information does the nurse need to provide to the AP?

a)

Specific hygiene products

b)

Timing of hygiene care

c)

Socioeconomic status

d)

The need for gender congruent caregiver

e)

Religious practices

63.

You are caring for a patient in an intensive care unit (ICU) who has pulled out his own IV line. You have tried restraint alternatives. Which of the following would you assess to determine appropriateness or reason to physically restrain the patient?

a)

Health care provider’s order

b)

Patient’s current behavior

c)

Current medications

d)

Serum electrolytes

e)

Presence of fever

64.

You complete a fall risk assessment on your assigned patient, who is 45 years old and has a history of cocaine use and liver failure. His laboratory results show an elevated prothrombin time. You determine that the patient is at high risk for falling. Which of the following measures are targeted to his fall risk status?

a)

Scheduling any oral medications at least 2 hours before bedtime

b)

Placing a low bed in room

c)

Placing the nurse call system within patient’s reach

d)

Using a bed exit alarm

e)

Providing patient with a protective head helmet when in chair or walking

65.

A nurse enters the hospital room of a patient who had a total knee replacement the day before and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following pose potential safety risks?

a)

A current safety inspection sticker is on the IV fluid pump

b)

A walker is positioned near the patient’s bedside

c)

The hospital bed is in the high position

d)

There is no gait belt at the bedside

e)

The overbed table with the patient’s glasses is positioned against the wall opposite the end of the bed

66.

Match the patient fall risks with the correct risk factor:

A 42-year-old patient who is recovering from anesthesia refuses assistance with walking to the bathroom

a)

Intrinsic Risk

b)

Extrinsic Risk

67.

Match the patient fall risks with the correct risk factor:

A 60-year-old patient with a history of falling in the last 6 months

a)

Intrinsic Risk

b)

Extrinsic Risk

68.

Match the patient fall risks with the correct risk factor:

A patient’s walking path has spilled fruit juice on the floor.

a)

Intrinsic Risk

b)

Extrinsic Risk

69.

Match the patient fall risks with the correct risk factor:

A 68-year-old patient recovering from a colon resection uses an IV pole to walk.

a)

Intrinsic Risk

b)

Extrinsic Risk

70.

Match the patient fall risks with the correct risk factor:

Patient is unable to identify own fall risks.

a)

Intrinsic Risk

b)

Extrinsic Risk

71.

Match the patient fall risks with the correct risk factor:

The physical therapist has not yet fitted a 62-year-old patient for a prescribed walker.

a)

Intrinsic Risk

b)

Extrinsic Risk

72.

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse?

a)

The first patient maintains eye contact with the nurse, is calm during the nurse’s assessment, and asks questions frequently

b)

The second patient is very drowsy, loses attention when the nurse asks questions, and mumbles when speaking

c)

The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume

d)

The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient

73.

The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patient says she is looking for the bathroom. Which interventions are appropriate for this patient?

a)

Ask the health care provider to order a restraint

b)

Provide scheduled toileting rounds every 2 to 3 hours

c)

Institute a routine exercise program for the patient

d)

Keep the bed in high position with side rails down

e)

Keep the pathway from the bed to the bathroom clear

74.

Match the fall prevention intervention with the scientific rationale:

Prioritize nurse call system responses to patients at high risk

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Ensures rapid response for help

75.

Match the fall prevention intervention with the scientific rationale:

Place patient in a wheelchair with wedge cushion

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Reduces chance of patient trying to get out of bed on own

76.

Match the fall prevention intervention with the scientific rationale:

Establish elimination schedule with bedside commode

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Reduces chance of patient trying to get out of bed on own

77.

Match the fall prevention intervention with the scientific rationale:

Use a low bed for patient

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Reduces chance of patient trying to get out of bed on own

78.

Match the fall prevention intervention with the scientific rationale:

Provide a hip protector

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Reduces chance of patient trying to get out of bed on own

79.

Match the fall prevention intervention with the scientific rationale:

Place nonskid floor mat on floor next to bed

a)

Maintains comfort and makes exit difficult

b)

Makes it difficult for patients with lower extremity weakness to stand

c)

Reduces slipping when walking

d)

Reduces fall impact

e)

Reduces chance of patient trying to get out of bed on own