Practice Quiz Answers
Unit 6
Question 1
The nurse has investigated safety hazards and recognizes that which one of the following
statements is accurate regarding safety needs?
A) Bacterial contamination of foods is uncontrollable.
B) Fire is the greatest cause of unintentional death.
C) Carbon monoxide levels should be monitored in home settings.
D) Temperature extremes seldom affect the safety of clients in acute care facilities.
Correct Answer: C
Explanation: Annual inspections of heating systems, chimneys, and appliances should be done
in private homes. Carbon monoxide detectors are available but should not be used as a
replacement for proper use and maintenance of fuel-burning appliances.
A. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for
the enforcement of federal regulations regarding the manufacture, processing, and distribution of
foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous
substances.
B. Motor vehicle accidents are the leading cause of unintentional death, not fire.
D. Temperature extremes can affect the safety of clients in acute care facilities, especially older
adults.
Question 2
A 1-year-old child is scheduled to receive an intravenous (IV) line. The most appropriate type of
restraint to use for this client to prevent removal of the IV line would be a(n):
A) Wrist restraint
B) Jacket restraint
C) Elbow restraint
D) Mummy restraint
Correct Answer: D
Explanation: A mummy restraint is used in the short-term for a small child or infant for
examination or treatment involving the head and neck. This would be the most appropriate type of
restraint to use for a 1-year-old who is going to receive an IV line.
A. The wrist restraint maintains immobility of an extremity to prevent the client from removing a
therapeutic device, such as an IV tube. It would not be the best choice for starting an IV on a 1year-old.
B. The jacket restraint is often used to prevent a client from getting up and falling. It is not the
best choice for starting an IV line.
C. An elbow restraint is commonly used with infants and children to prevent elbow flexion, such
as after an IV line is in place.
Question 3
The nurse assesses that the client may need a restraint and recognizes that:
A) An order for a restraint may be implemented indefinitely until it is no longer required by the
client.
B) Restraints may be ordered on an as-needed basis.
C) No order or consent is necessary for restraints in long-term care facilities.
D) Restraints are to be periodically removed to have the client re-evaluated.
Correct Answer: D
Explanation: Restraints must be periodically removed, and the nurse must assess the client to
determine if the restraints continue to be needed.
A. This is not a true statement. A physician’s order for restraints must have a limited time frame. If
the orders are renewed, it should be done so within a specified time frame according to the
agency’s policy.
B. Restraints are not to be ordered prn (as needed).
C. The use of restraints must be part of the client’s medical treatment. An order or consent is
necessary for restraints in long-term care facilities.
Question 4
On entering the client’s room, the nurse sees a fire burning in the trash can next to the bed. The
nurse removes the client and calls in the fire. The next action of the nurse is to:
A) Extinguish the fire
B) Remove all of the other clients from the unit
C) Close all the doors of client rooms
D) Move the trash can into the bathroom
Correct Answer: C
Explanation: The next action the nurse should take is to confine the fire by closing doors and
windows and turning off oxygen and electrical equipment.
A. The nurse should extinguish the fire by using an extinguisher after closing the doors of the
client rooms.
B. After activating the alarm, the nurse should close all the doors, not remove all of the other
clients from the unit.
D. This would not be an appropriate action, as the nurse could get burned in attempting to move
the trash can.
Question 5
Which one of the following statements by the parent of a child indicates that further teaching by
the nurse is required?
A) “Now that my child is 2 years old, I can let her sit in the front seat of the car with me.”
B) “I make sure that my child wears a helmet when he rides his bicycle.”
C) “I have spoken to my child about safe sex practices.”
D) “My child is taking swimming classes at the community center.”
Correct Answer: A
Explanation: This statement indicates that further teaching is required. Children weighing less
than 80 pounds or younger than 8 years should always be in an age/weight-appropriate car seat
that has been installed according to manufacturers directions. In cars with a passenger air bag,
children younger than 12 should be in the back seat.
B. This is an appropriate safety measure to reduce injuries from falling off a bike or being hit by a
car.
C. This is an important safety measure, as many adolescents begin sexual relationships.
D. This is an appropriate safety measure that may someday save a child’s life.
Question 6
A 75 year old client, hospitalized with a stroke, becomes disoriented at times and tries to get out
of bed, but is unable to ambulate without help. What is the most appropriate nursing measure?
A) Restrain the client in bed
B) Ask a family member to stay with the client
C) Check the client every 15 minutes
D) Use a bed exit safety monitoring device
Correct Answer: D
Explanation: The bed alarm is the least restrictive device and allows the client to feel
independent and alerts the nurse and staff when the client needs assistance.
A. can increase agitation and confusion and removes independence.
B. would help but transfers responsibility to the family member.
C. Client could fall during unobserved times and is not a realistic answer for the nurse.
Question 7
A mother of a young child enters the kitchen and finds the child on the floor. A bottle of cleanser
is next to the child, and particles of the substance are around the child’s mouth. The parent’s first
action should be to:
A) Call the Poison Control unit
B) Provide ipecac syrup
C) Check the child’s airway and breathing
D) Remove the particles of cleanser from the mouth
Correct Answer: C
Explanation: The first action is to assess for airway patency, breathing, and circulation.
A. After checking the child’s airway, breathing, and circulation, the parent should remove any
particles of cleanser from the mouth. The parent should identify the type and amount of
substance ingested and then call the Poison Control unit.
B. The parent should administer ipecac syrup only if instructed to induce vomiting by the Poison
Control unit. Administering ipecac is not the parent’s first action.
D. Removing the particles of cleanser is not the parent’s first action. The parent may do so after
assessing the child’s airway, breathing, and circulation.
Question 8
A visiting nurse completes an assessment of the ambulatory client in the home and determines
the nursing diagnosis of “Risk for injury related to decreased vision”. Based on this assessment,
the client will benefit the most from:
A) Installing fluorescent lighting throughout the house
B) Becoming oriented to the position of the furniture and stairways
C) Maintaining complete bed rest in a hospital bed with side rails
D) Applying physical restraints
Correct Answer: B
Explanation: Orienting the client to the position of furniture in the room and stairways is the best
intervention to help prevent falls for the client with decreased vision.
A. Attempts should be made to reduce glare. Light bulb wattage can be increased to help improve
visibility. The best intervention to prevent falls is first to orient the client to the surroundings.
C. Maintaining complete bed rest is not the best option. Complete bed rest can cause other
health problems because of a lack of mobility.
D. The client should not be restrained for poor vision. Attempts should be made to help
compensate for the decreased vision to prevent falls.
Question 9
A 79-year-old resident in a long-term care facility is known to “wander at night” and has fallen in
the past. Which of the following is the most appropriate nursing intervention?
A) An abdominal restraint should be placed on the client during sleeping hours
B) The client should be checked frequently during the night
C) A radio should be left playing at the bedside to assist in reality orientation
D) The client should be placed in a room away from the activity of the nursing station
Correct Answer: B
Explanation: Alternatives to restraints should be attempted first. (A physician’s order is required
for restraints to be applied). The most appropriate intervention is to check on the client frequently.
A. Alternatives to restraints should be attempted first.
C. A radio may help orient a client to reality. However, the most appropriate intervention for the
client who wanders is to check on the client frequently.
D. Clients who wander should be assigned to rooms near the nurse’s station and checked on
frequently.
Question 10
The workmen cause an electrical fire when installing a new piece of equipment in the intensive
care unit. A client is in the next room. The first action the nurse should take is to:
A) Pull the fire alarm
B) Attempt to extinguish the fire
C) Call the physician to obtain orders to take the client off the ventilator
D) Remove the client from the area
Correct Answer: D
Explanation: If there is a fire, the nurse should move the client away from the fire.
A. The first action of the nurse is not to pull the fire alarm. The workmen could do that.
B. The workman can attempt to extinguish the fire. The nurse should attend to the client who is
closest to the fire in the next room.
C. The nurse should not call the doctor to obtain orders to take the client off the ventilator, as this
will take valuable time. The client must be moved away from the fire and the source of oxygen
must be discontinued, as it is combustible. The client will need to be manually resuscitated with
an Ambu-bag.
5/10