fundamentals

Question 1

Restraints

Answer 1

Restraints are only used as a last resort if there
is risk for harm and only after less restrictive
measures have failed.

Question 2

Restraints

Answer 2

For clients in restraints, perform neurovascular
assessments every 2 hours, checking skin color,
temperature, and pulse. Ensure you can fit
2 fingers underneath the restraint.

Question 3

Fall Prevention

Answer 3

The two most important interventions to prevent falls
are ensuring the call light is within reach and
performing hourly rounding.

Question 4

Fall Prevention

Answer 4

To prevent falls at home, clients should
remove clutter and rugs from walkways.

Question 5

‘RACE’ & ‘PASS’

Answer 5

In the event of a fire, the nurse should prioritize actions using RACE (Rescue clients, Activate alarm,
Confine fire, Extinguish fire) and PASS (Pull pin, Aim at base of fire, Squeeze handle, Sweep from side to side).

Question 6

Impaired balance

Answer 6

Orthostatic hypotension
Medications
(benzodiazepines, opioids)

Question 7

Impaired mental
status

Answer 7

Confusion and
disorientation
Impulsivity

Question 8

Impaired sensory
perception

Answer 8

Visual or hearing
impairment
Paresthesia

Question 9

Impaired bladder
or bowel function

Answer 9

incontinence
Urgency, frequency
Diuretic use

Question 10

Environmental
hazards

Answer 10

Throw rugs, cords
Dark, poorly-lit room