NR-224 Fundamentals – Skills - Set 4 - Part 2

Correct Answer: Two hours, then the order requires renewal

For violent or self-destructive behavior the maximum length of one order is set by age: four hours for adults, two hours for ages nine through seventeen, and one hour for children under nine. Option a is incorrect because the one-hour figure belongs to children younger than nine years and also matches the separate face-to-face deadline, which is why students choose it. Neither of those describes the order limit for a fourteen-year-old. Option b is incorrect because four hours is the adult limit for clients eighteen and older. This client falls in the nine through seventeen band, where the regulation cuts the permitted duration in half. Option d is incorrect because twenty-four hours is the total period across which orders may be renewed, not the length of any single order. At that point the practitioner must see and assess the client in person.

Correct Answer: Remove the restraints and document the response

The order sets a ceiling, not a schedule. Once the client no longer poses the danger the restraint was applied to prevent, the device comes off immediately, and the nurse documents the time and the client's response. Option a is incorrect because running an order to its expiration treats a legal maximum as a required duration. Restraint is always temporary, and continuing it once the justifying behavior has resolved becomes restraint for convenience. Option b is incorrect because reducing to one wrist is still a restraint applied to a client who now meets every criterion for release. Stepping down the level of restriction is not the same as ending it. Option c is incorrect because a renewal presumes the danger persists, and nothing in this assessment supports that. Asking the provider to extend an unnecessary restraint also documents a need the nurse has already disproved at the bedside.

Correct Answer: Cannot feel the legs after epidural anesthesia

Lower extremity sensation and motor function must return fully before a client who received epidural or spinal anesthesia stands. Walking on legs the client cannot feel or control guarantees a fall, so the walk is held and the provider told. Option a is incorrect because mild incisional soreness is expected after surgery and is managed rather than avoided. The nurse gives the ordered analgesic and times the walk for peak effect, since pain that is untreated produces guarding and shuffling. Option c is incorrect because well fitting nonskid slipper socks are exactly what the nurse wants on the client's feet. Traction is a fall prevention measure, and this finding supports going ahead with the walk rather than cancelling it. Option d is incorrect because tubes and lines are secured and managed, not treated as a barrier. Drainage bags travel below the bladder, the intravenous pole is guided by a second person, and nothing trails on the floor.

Correct Answer: I wear shoes and socks even inside my own house.

Neuropathy removes the warning that an injury has happened, so nothing may touch the foot that could puncture or burn it. Shoes and socks indoors and outdoors are the barrier that prevents the small wound that becomes an ulcer. Option a is incorrect because the foot is the one part of the body that cannot judge temperature here. Water is tested with a thermometer, the wrist or the elbow, and it must be warm rather than hot. Option b is incorrect because over the counter corn and callus products are salicylic acid caustics. On an insensate, poorly perfused foot they burn the skin chemically and open an ulcer, so a podiatrist removes calluses instead. Option d is incorrect because prolonged soaking macerates skin and softens it until it splits. Long immersion also carries a burn risk when sensation is absent, which is why washing is brief and drying between the toes matters more.

Correct Answer: I will chart that an occurrence report was completed.

The medical record must stay silent about the occurrence report. Naming it in the chart can pull an internal quality document into discovery and destroy the protection it carries, so this statement needs correction. Option b is incorrect because routing the report to risk management is exactly where it belongs. Administration and the facility insurer use it to examine the system, identify trends and assess liability, so this statement is accurate. Option c is incorrect because objective description of the event and the assessment findings is required charting. The chart documents what happened to the client and what the nurse did about it, which the new nurse stated correctly. Option d is incorrect because the person who witnessed or discovered the event is the one who completes the form. Firsthand knowledge is what makes the account usable, and that assignment is standard practice.

Correct Answer: A two wheeled walker with rear tips

A two wheeled walker is pushed rather than lifted, so it suits a client who lacks the arm strength to pick up a standard frame. The rear tips still catch the floor when weight is applied, preserving stability. Option a is incorrect because a cane sits at the bottom of the stability ladder and suits mild one sided weakness. Moving this client from a walker to a cane strips away support just as fatigue is worsening. Option b is incorrect because a rollator rolls freely on four wheels and is the least stable walker type. A client with Parkinson disease and festinating gait can be carried forward by it, and hand brakes require grip strength. Option c is incorrect because crutches demand more upper body strength than the walker this client already cannot lift. They are prescribed for temporary weight bearing restrictions in a younger, stronger client, not for progressive neurologic weakness.

Correct Answer: Notify the provider of possible paraphimosis immediately

A retracted foreskin left behind the glans forms a constricting band that blocks venous and lymphatic drainage. Paraphimosis is a urological emergency, so the provider is contacted at once before ischemia and tissue necrosis develop. Option b is incorrect because heat and watchful waiting do nothing about a mechanical constriction. Swelling worsens with every passing hour, arterial flow eventually fails, and delay is exactly what turns a reducible foreskin into a necrotic glans. Option c is incorrect because education addresses the next client, not this one. The teaching does need to happen, since replacing the foreskin after cleaning or catheter care prevents the whole problem, but the swollen glans comes first. Option d is incorrect because charting records a problem without treating it. Objective documentation of the appearance, the time and the client's report is required, yet it follows the call that gets the constriction relieved.

Correct Answer: Inspect the sling for fraying before use

Inspecting a sling for fraying, worn stitching and damaged loops is a concrete observation with a clear standard, so it can be delegated. Deciding, assessing and evaluating are nursing judgments that stay with the nurse. Option a is incorrect because choosing the handling method follows from the nurse's assessment of mobility, weight bearing and cooperation. That decision sets the safety plan for the move and belongs to the licensed nurse. Option c is incorrect because weight-bearing status is a physical assessment that determines which device is safe. Assistive personnel may report what they see the client do, yet grading that ability is outside their scope. Option d is incorrect because evaluation is the final step of the nursing process and cannot be transferred. Judging how a client tolerated a transfer requires interpreting vital signs, color, pain and alignment together.

Correct Answer: Ask the teenager directly about thoughts of suicide

Withdrawal after a loss plus unsecured firearms is a lethal-means risk. The nurse asks directly about suicidal ideation, since asking does not plant the idea, and then addresses locking the firearms away. Option a is incorrect because normalizing the mood change closes the conversation before the risk is known. Suicide is a leading cause of adolescent death, and withdrawal from friends is one of its warning signs. Option b is incorrect because a month is far too long to wait when warning signs and accessible firearms are both present. Risk of this kind is assessed during the visit in which it surfaces. Option c is incorrect because watching accounts substitutes surveillance for a direct question. Monitoring may have a place later in the plan, but it does not tell the nurse whether this teenager is thinking about dying.

Correct Answer: A registered nurse trained for this evaluation

Federal regulation names exactly two categories for the one-hour evaluation: a physician or other licensed practitioner, and a registered nurse who has completed the required training. The trained nurse must then consult the attending as soon as possible. Option a is incorrect because a licensed practical nurse is not one of the two categories the regulation lists. Practical nurses may assist with monitoring and care, yet the one-hour evaluation demands an assessment authority they do not hold. Option b is incorrect because restricting the evaluation to the ordering physician adds a limit the rule does not impose. Any physician or other licensed practitioner responsible for the client may perform it, and so may a trained registered nurse. Option d is incorrect because a title on the shift roster confers nothing here. What qualifies a nurse is documented completion of the restraint training the regulation requires, not the assignment held that day.

Correct Answer: Place the client in high Fowler position

Raising the trunk to sixty degrees or more lets the abdominal organs drop away from the diaphragm, so it descends further and tidal volume increases. High Fowler is the position for severe dyspnea. Option a is incorrect because lying flat lets the abdominal contents press upward against the diaphragm. The client already cannot move enough air, and supine positioning takes away the little chest expansion that remains. Option c is incorrect because a head down tilt drives the abdominal viscera into the diaphragm and impairs ventilation further. That position belongs to central line insertion and postural drainage, never to acute respiratory distress. Option d is incorrect because turning onto the side helps only when one lung is diseased and the healthy lung is placed down. This client needs maximal expansion of both lungs, which upright sitting provides.

Correct Answer: Assess consciousness and check for obvious injury

Assessment precedes intervention, and level of consciousness with airway, breathing and circulation decides whether this is a fall or an arrest. Injury status also determines whether moving the client is safe, so nothing else can come first. Option a is incorrect because lifting a client off the floor before injury is ruled out can convert an undisplaced hip fracture or an unstable cervical spine into permanent damage. Movement waits until the assessment clears it. Option b is incorrect because both steps are prevention aimed at the next fall rather than a response to this one. Correcting the room while a possibly injured client lies on the floor inverts the order of priority. Option d is incorrect because notification follows assessment. The nurse has nothing meaningful to report until consciousness, vital signs, neurological status and injuries are known, and a provider cannot give useful orders without those findings.

Correct Answer: Position the client in the Trendelenburg position

Head down tilt distends the subclavian and jugular veins and raises central venous pressure. The fuller vein is easier to cannulate, and the raised pressure lowers the risk of air being drawn into the circulation. Option a is incorrect because the orthopneic position seats the client leaning forward over an overbed table. It relieves severe dyspnea by anchoring the shoulder girdle, and it puts the insertion site out of reach. Option b is incorrect because Sims is a semi prone side lying position used for enemas, rectal procedures and drainage of oral secretions. Rolling the client onto the side would bury the subclavian landmarks. Option c is incorrect because sitting the client upright drains blood away from the great veins and lowers central venous pressure. That collapses the target vein and increases the chance of air embolism during insertion.

Correct Answer: Remove the pump from service and tag it

Damaged electrical equipment comes out of the room immediately and is tagged for biomedical engineering. A frayed cord and a bent ground prong both create a shock hazard that no field repair makes safe. Option b is incorrect because tape hides damage without correcting it. The insulation and the internal conductors are already compromised, and a taped cord still carries current toward a client and a nurse. Option c is incorrect because the ground pin is the path that carries stray current safely away from the equipment case. Defeating it with an adapter turns a fault into a shock delivered through whoever touches the pump. Option d is incorrect because documentation alone leaves the hazard plugged in beside the client. Charting is a record of what was done, and nothing has been done until the device is out of the room.

Correct Answer: Padding the side rails and clearing bedside clutter

Padding side rails and removing hazards from the bedside is a standardized environmental task with a predictable outcome and no judgment attached, which places it squarely within the assistive personnel scope of practice. Option a is incorrect because evaluating a client's response to medication is an assessment reserved for the registered nurse. Assistive personnel can report what they observe, but interpreting therapeutic effect is nursing judgment. Option b is incorrect because the decision to contact a provider rests on clinical analysis of the event and the client's status. That analysis is part of the nursing process and cannot be handed off. Option c is incorrect because client and family teaching is a licensed responsibility. Assistive personnel may reinforce information the nurse has already given, yet the initial instruction and the evaluation of learning stay with the nurse.

Correct Answer: The client who has fallen twice this year

A prior fall integrates every unmeasured balance, strength and cognitive deficit the client has, and meta-analytic data place fall history at roughly three times the odds of falling. It outweighs age, a single medication, or vision correction. Option a is incorrect because age by itself is only a modest predictor. It acts as a background multiplier on strength, balance and drug clearance, so an eighty-four-year-old with no other history ranks below a repeat faller. Option c is incorrect because a diuretic raises risk through urgency, nocturia and volume depletion. Those effects are genuine and modifiable through early dosing and scheduled toileting, and they rank below a documented history of repeated falls. Option d is incorrect because multifocal lenses distort depth at floor level, chiefly on stairs, which is a narrower hazard than the one described here. Vision impairment carries a far smaller odds ratio than a recent fall.

Correct Answer: Apply foot boots that hold the ankles neutral

Foot drop develops when the unopposed calf muscles hold the ankle in plantar flexion until it fixes there. Boots keep the ankle at a neutral ninety degrees so the foot can still rest flat later. Option b is incorrect because a pillow under the knees compresses the popliteal vessels and encourages hip and knee flexion contracture. It also does nothing to lift the ankle out of plantar flexion. Option c is incorrect because tight linen is the very force pushing the toes down. Bedding should be loosened or lifted with a bed cradle rather than pulled taut across the toes. Option d is incorrect because a trochanter roll is placed along the outer thigh to stop the hip turning outward. Positioned near the ankle it supports nothing and holds no joint at any useful angle.

Correct Answer: I prop her on a soft blanket so she sleeps longer.

Soft bedding and propping are the sleep hazards that kill infants. Safe sleep is on the back, on a firm flat surface, alone in the crib, with no pillows, bumpers, blankets or soft toys. Option a is incorrect because back sleeping in an empty crib is exactly what the nurse wants to hear. This statement shows the parent already follows the single highest-yield teaching point of the first year. Option b is incorrect because a rear-facing seat in the back seat is the correct configuration at this age. Keeping the infant away from an active passenger airbag is the reason the back seat is required. Option d is incorrect because testing bath water temperature is sound scald prevention. Paired with a water heater set no higher than about one hundred twenty degrees, it protects skin that burns faster than an adult's.

Correct Answer: Brush over a lined sink and store in water

The sink is lined with a cloth so a dropped denture does not shatter. Cleaning uses a soft brush with cool or lukewarm water, and the dentures are stored covered in water so they cannot dry out. Option a is incorrect because bleach and other household abrasives eat into the acrylic and discolor it. Dentures also warp and become brittle when stored dry, so a covered container of water is part of the same routine. Option b is incorrect because heat distorts the denture base and ruins the fit permanently. Tissue is worse still, since wrapped dentures are mistaken for trash and thrown away, which is one of the commonest losses on a hospital ward. Option c is incorrect because alcohol dries and damages denture material rather than cleaning it. Leaving the plates uncovered on a bedside surface invites drying, breakage and loss, so a labeled closed container is always used.

Correct Answer: Contact the provider because the order is invalid

As-needed and standing restraint orders are prohibited outright. Each episode requires a new, individualized order naming the specific behavior, the type of restraint and the duration, so this order cannot be carried out as written. Option a is incorrect because acting on the order carries out the very practice regulation forbids. The prohibition exists so that a restraint is never reapplied on a nurse's judgment alone after the previous episode ended. Option c is incorrect because filing an invalid order and adding assessments does not repair the defect. Hourly reassessment is good practice, yet the document authorizing restraint still fails the legal requirement for a single, episode-specific order. Option d is incorrect because a second nurse's signature cannot create authority neither nurse possesses. Only the physician or other licensed practitioner responsible for this client may write a restraint order, and that order must name a defined behavior.