NURS 204 EXAM 2 NEWEST 2024-2025 ACTUAL
EXAM COMPLETE 100 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
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. - CORRECT
ANSWER-Answer: a
Rationale; 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.
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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 - CORRECT ANSWER-Answer: b
Rationale; 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.
c. Restraint allows for 3 to 4 fingers width between restraint and
patient's wrist.
d. Restraint is secured to the bedframe. - CORRECT ANSWER-
Answer: d
Rationale; 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
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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. - CORRECT
ANSWER-Answer: d
Rationale; 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.
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e. Assess and document IV site every 8 hours. - CORRECT
ANSWER-Answer: a, b
Rationale; 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.
. 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. -
CORRECT ANSWER-Answer: a, b, c
Rationale; 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
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