While making rounds, the nurse finds a patient on the floor in the hallway. Which action will the
nurse do first?
-assess the patient for injury
-transfer the patient back to bed
-assist the patient to a wheelchair
-report the patient's condition to the physician - ANS -assess the patient for injury
Which action should the nurse take to prevent accidents?
-apply a restraint when the patient is in the wheelchair to keep them from falling
-determine the strength of the patient
-turn all the lights off in the room so the patient can sleep
-provide a cane for walking if the patient is weak - ANS -determine the strength of the patient
When caring for a patient who is able to get out of bed independently and safely, the nurse will
-leave one side rail at the foot of the bed up
-leave one side rail up when there are only two side rails on the bed
-leave both side rails up in a two side rail bed
-leave all four side rails up for all patients at all times - ANS -leave one side rail up when there
are only two side rails on the bed
The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never
Event?
-a sponge is left in the patient's incision
-pulmonary embolism after lung surgery
-no blood incompatibility occurs with a blood transfusion
-development of stage II pressure ulcer - ANS -a sponge is left in the patient's incision
The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse
assesses the patient and finds no apparent changes in the previous assessment. The nurse
assists the patient back to bed. Which action should the nurse take next?
-notify the health care provider
-do nothing, no harm has occurred
-notify the family
-complete an incident report - ANS -notify the health care provider
The nurse is teaching a group of older adults at an assisted living facility about age related
physiological changes affecting safety. Which question would be most important for the nurse to
ask this group?
-Are you able to taste spices like before?
-Are you able to hear the tornado sirens in your area?
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