NURS 320 - Exam 1 Practice Questions

NURS 320 - Exam 1 Practice  Questions with Complete Solutions A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the

correct order:

• Have patient rise from straight-back chair without using

arms for support.

• Begin timing.
• Tell patient to walk 10 feet as quickly and safely as

possible to a line you marked on the floor, turn around, walk back, and sit down.

• Check time elapsed.
• Look for unsteadiness in patient's gait.
• Have patient return to chair and sit down without using

arms for support. - Correct Answers ✅3, 1, 2, 5, 6, 4.These are the correct steps for performing the TUG.A nurse knows that the people most at risk for accidental

hypothermia are: (Select all that apply)

• People who are homeless.
• People with respiratory conditions.
• People with cardiovascular conditions.
• The very old.
• People with kidney disorders. - Correct Answers ✅1, 3,

4. 1 / 4

NURS 320 - Exam 1 Practice  Questions with Complete Solutions Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia.A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent?

• Only infants and toddlers need to ride in the back seat.
• All toddlers can move to a forward facing car seat when

they reach age 2.

• Toddlers must reach age 2 AND the height / weight

requirement before they ride forward facing.

• Toddlers must reach age 2 OR the height or weight

requirement before they ride forward facing. - Correct Answers ✅4 The American Academy of Pediatrics (2011a) recommends that all infants and toddlers ride in the back seat with a rear- facing-only seat and rear-facing convertible seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat.The nursing assessment of a 78 year old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 2 / 4

NURS 320 - Exam 1 Practice  Questions with Complete Solutions

• Activity intolerance
• Impaired bed mobility
• Acute pain
• Risk for falls - Correct Answers ✅4

For adults age 65 and older, orthostatic hypotension, fear of falling, and weakness on one side are risks for the nursing diagnosis of Risk for Falls.A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly?(Select all that apply)

• Inadequate lighting
• Throw rugs
• Multiple medications
• Doorway thresholds
• Cords covered by carpets
• Staircases with handrails - Correct Answers ✅1,2,3,4,5

Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Multiple medications also contribute to fall risk. 3 / 4

NURS 320 - Exam 1 Practice  Questions with Complete Solutions You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order.

• Be sure that patient is comfortable with arm in anatomic

alignment

• wrap wrist with soft part of restraint toward skin and

secure snugly

• Identify patient using two identifiers
• Introduce self and ask patient about his feelings of being

restrained

• Assess condition of skin where restraint will be placed -

Correct Answers ✅3,4,1,5,2 The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone.What is the best action to take in this situation? (Select all that apply)

• Contact the nursing supervisor
• Restrict the family's visiting privileges
• Ask the family to stay with the patient if possible
• Inform the family of the risks associated with side-rail use
• Thank the family for being conscientious and put the four

rails up

• Discuss alternatives that are appropriate for this patient

with the family - Correct Answers ✅3, 4, 6

• / 4