Download NSE111 Exam Questions with Verified Solutions: Nursing Fundamentals and more Exams Nursing in PDF only on Docsity!
NSE
NSE111 EXAM QUESTIONS WITH CORRECT
VERIFIED SOLUTIONS 100% GUARANTEED
PASS (2025/2026)
The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly d. Dirty floors, hallways blocked, medication room locked, and alarms set - ANS ✓ANS: C The four categories are falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction or infection control issues or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues, and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are patient satisfaction issues and examples of following a procedure correctly. Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using
NSE
a. Sequential compression devices. b. A measuring device that measures urine. c. Computer-based documentation. d. A manual medication-dispensing device - ANS ✓ANS: A Sequential compression devices are used on a patient's extremities to assist in prevention of deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include a. Encouraging visitors in the early evening. b. Placing all four side rails in the "up" position. c. Checking on the patient once a shift. d. Placing a high risk for falls armband on the patient. - ANS ✓ANS: D Placing a high risk for falls armband on the patient encourages communication among the whole interdisciplinary team. Anyone who interacts with the patient should see this armband, understand its meaning, and assist the patient as necessary. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. b. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. c. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital.
NSE
The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse? a. "I try to exercise, so I walk that block almost every day." b. "I waited and stepped out when the traffic sign said go." c. "The car was going too fast, the speed limit is 20." d. "I was so surprised; I didn't see or hear the car coming." - ANS ✓ANS: D The patient did not see or hear the car coming. As patients age, sensory impairment can increase the risk for injury. This statement by the patient would require follow-up by the nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of development. The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car. The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? a. Ask the patient why she has been wandering around the house. b. Introduce self and ask the patient her name. c. Take the patient's blood pressure, pulse, temperature, and respiratory rate. d. Immediately do a complete head-to-toe neurologic assessment. - ANS ✓ANS: B Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment. The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to
NSE
a. Carry out the role and responsibilities of the nurse quickly and efficiently. b. Cluster all patients with the same symptoms to a specific part of the department. c. Determine the biologic agent and manage all patients using Standard Precautions. d. Prepare for post-traumatic stress associated with this bioterrorist attack
- ANS ✓ANS: C It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain diseases, additional precautions may be necessary. Clustering patients may be helpful with staffing and, depending on the illness, may decrease the spread. All nurses every day should carry out their roles quickly and efficiently. Psychosocial concerns are important but are not the first priority at this moment. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of a. Risk for poisoning. b. Knowledge deficit. c. Impaired home maintenance. d. Risk for injury. - ANS ✓ANS: D The patient's behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.
NSE
for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for poisoning, imbalanced body temperature, or suffocation. The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? a. Activate the alarm. b. Extinguish the fire. c. Remove the patient. d. Confine the fire. - ANS ✓ANS: C Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation. The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? a. "The number for poison control is 800- 222 - 1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac." - ANS ✓ANS: D Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning. This medication should not be administered to the child. The poison control number is 800- 222 - 1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the medication is eliminated. Loss of consciousness associated with poisoning requires calling 911.
NSE
An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? a. Place the patient in restraints. b. Lock beds and wheelchairs when transferring. c. Place a bath mat outside the tub. d. Silence fall alert alarm upon request of family - ANS ✓ANS: B Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls. Patients are not automatically placed in restraints. The restraint process consists of many steps, including thorough assessment and exhausting of alternatives. All mats and rugs should be secured to help prevent falls. Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment. The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? a. Ask the family to leave the room. b. Check for a pulse. c. Begin compressions. d. Defibrillate the patient. - ANS ✓ANS: B In this scenario, the patient is in a hospital setting, and it has been determined that the patient is not conscious and is not breathing. The next step is to check the pulse. An electrical shock can interfere with the heart's normal electrical impulses and can cause arrhythmias. Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and defibrillation. A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take?
NSE
b. "The medications can be picked up at the pharmacy on the way out of the hospital." c. "I need to be sure to give the patient leftover medications from the medication drawer." d. "I need to remember to teach the patient to take all medications at the same time of the day." - ANS ✓ANS: A Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety. Medications are not distributed by the hospital, and medications do not need to be administered at the same time each day. A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take? (Select all that apply.) a. Agree upon and make time for the patient to talk. b. Use active listening skills and therapeutic touch as appropriate. c. Teach stress reduction strategies. d. Inform patient that stressed individuals are more likely to have accidents. e. Agree to witness telephone conversations with separated husband. f. Refer the patient to the nurse's church marriage counselor. - ANS ✓ANS: A, B, C, D Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services
NSE
that may include a list of possible counselors from which the patient could choose. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.) a. Watering outdoor plants with a nozzle and hose b. Purchasing light bulbs with strength greater than 60 watts c. Missing yearly eye examinations d. Using bathtubs without safety strips e. Unsecured rugs throughout the home f. Walking to the mailbox in the summer - ANS ✓ANS: A, C, D, E Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home. Exercise is beneficial and increases strength, which helps with the prevention of falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength of 60 watts or higher for the home. Which of the following concepts are important to utilize when evaluating orders for restraints (Select all that apply.) a. Behaviors that necessitate the use of restraint are part of the nursing plan of care. b. A physician's order is required for restraint and includes a face-to-face evaluation. c. The physician's preference for the format of the order can override agency policy. d. Orders are time limited. Restraints are not ordered prn (as needed). e. It should be specified that restraints are to be removed periodically. f. Restraint orders are time dated and signed by the physician - ANS ✓ANS: B, D, E, F
NSE
b. Assess the home for items that could harm the patient during a seizure. c. Provide information on how to obtain a Medical Alert bracelet. d. Teach the patient to communicate to the caregiver plans for bathing. e. Discuss with family steps to take if the seizure does not discontinue. f. Demonstrate how to restrain the patient in the event of a seizure. - ANS ✓ANS: B, C, D, E Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) a. All occupants have left the home. b. Fire department has been called. c. Fire is confined to one room. d. An exit route is available. e. The correct extinguisher is available. f. The nurse thinks she can use the fire extinguisher. - ANS ✓ANS: A, B, D, E In a home setting, if the nurse is present during a fire, she first should remove all occupants and then should call the fire department by dialing
- If the fire is small — not confined to just one room (this could be too large for the fire extinguisher), if the correct extinguisher is available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area from side to side) to activate the extinguisher.
NSE
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Await direction from the fire department. e. Evacuate everyone from the building. f. Review "Stop, drop, and roll" with the nursing staff - ANS ✓ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of "stop, drop, and roll," although important, is not a priority at this time. The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.) a. The patient states that her gown is soiled and needs changing. b. Attempts to distract the patient with television are unsuccessful. c. The patient has been placed in bilateral wrist restraints at 0815. d. One family member has gone to lunch. e. Bilateral radial pulses present, 2+, hands warm to touch f. Released from restraints, active range-of-motion exercises complete - ANS ✓ANS: B, C, E, F Attempts at alternatives are documented in the medical record, as are type of restraint and time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation, and position are documented, along with release from restraints and patient response. Comments about hygiene or the activities of one
NSE
individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient. The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? a. 65° F to 75° F b. 60° F to 75° F c. 15° C to 17° C d. 25° C to 28° C - ANS ✓ANS: A The comfort zone for most individuals is the range between 65° F and 75° F (18.3° C to 23.9° C). The other ranges do not reflect the average person's comfort zone. A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure - ANS ✓ANS: B Hypothermia is defined as a core body temperature of 95° F or below. Homeless individuals are more at risk for hypothermia owing to exposure to the elements. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to a. Use alcohol-based gel on hands. b. Wash hands with soap and water.
NSE
c. Remove eye protection and dispose of in garbage. d. Remove gloves and dispose of in garbage. - ANS ✓ANS: D After disposing of the urine, the first step in removing personal protective equipment is removing gloves and disposing of them properly. In this scenario, the next step would be to remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is indicated for routine decontamination of hands. The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to a. Distinguish the correct surgical site. b. Label the correct patient. c. Comply with the surgeon's preference. d. Adhere to the correct regulatory standard. - ANS ✓ANS: A The purpose of writing on the surgical site as part of the Universal Protocol from the Joint Commission is to distinguish the correct site on the correct patient and match with the correct surgeon for patient safety and prevention of wrong site surgery. All patients who are having an invasive procedure should receive labeling in many different ways, including the record and patient armbands. Writing in indelible ink may comply with the surgeon's preference, but safety is the driving factor. Although labeling of the site helps to meet regulatory standards, this is not the reason to do this activity — the reason is to keep the patient safe. The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to a. Do nothing, no harm has occurred. b. Assess and monitor the patient. c. Notify the physician, treat and document. d. Complete an incident report. - ANS ✓ANS: B After providing an incorrect medication, assessing and monitoring the patient to determine the effects of the medication is the first step. Notifying
NSE
a. Learning to walk. b. Trying to pull up on furniture. c. Being dropped by a caregiver. d. Growing ability to explore and oral activity. - ANS ✓ANS: D Injury is a leading cause of death in children over age 1, which is closely related to normal growth and development because of the child's increased oral activity and growing ability to explore the environment. A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of a. a bicycle helmet. b. swimming goggles. c. soccer shin guards. d. baseball sliding shorts. - ANS ✓ANS: A Bicycle-related injuries are a major cause of death and disability among children. Proper fit of the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death. The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? a. Adolescents need unsupervised time with friends two to three times a week. b. Parents and friends should teach adolescents how to drive. c. Adolescents need information about the effects of beer on the liver. d. Adolescents need to be reminded to use seatbelts on long trips - ANS ✓ANS: C Providing information about drugs and alcohol is important because adolescents may choose to participate in risk-taking behaviors.
NSE
Adolescents need to socialize but need supervision. Parents can encourage and support learning processes associated with driving, but organized classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time. The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? a. "Our campus is safe; we leave our dorms unlocked all the time." b. "As long as I have only two drinks, I can still be the designated driver." c. "I am young, so I can work nights and go to school with 2 hours' sleep." d. "I guess smoking even at parties is not good for my body." - ANS ✓ANS: D Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night. The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to remember the name of the person you just met?" d. "Are you able to open a jar of pickles?" - ANS ✓ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Although age-related changes may cause a decrease in sight that affects reading, and although difficulties in remembering short-term information and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the priority.
