Code Brown Commence Basic Life Support (DRSABCD)
Question 1
For each of the emergency codes listed below select the correct response that would be
undertaken in a hospital setting.
Code Response
Code Yellow Remain calm, remove people from immediate danger (if safe to do so), dial
the hospital emergency number, close doors and windows, extinguish,
evacuate
Code Brown Commence Basic Life Support (DRSABCD) until further medical assistance
arrives
Code Purple Leave item alone, dial hospital emergency number, follow directions of
senior staff, do not use mobile phones or radio frequency equipment
Code Orange Can include hazardous substances. Remain calm, dial the hospital
emergency number, move patients staff and visitors who are in immediate
danger (only if safe to do so)
Code Black Depends on the nature of the emergency and availability of emergency
resources.
Code Blue Obey offender’s instructions (if does not place you in additional danger),
remain calm, no sudden or unexpected movements, remove yourself from
the situation as soon as safe to do so, dial the hospital emergency number if
able, use duress alarm if available
Code Red Remove people from immediate danger in a quick and save manner, follow
priority of evacuation procedures i.e. ambulant patients and visitors first, do
not use a lift – always use the stairs.
4/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 2 (marked out of 5- 1 mark for correctly chosen answer)
Using the SA Health Falls and Fall-injury Risk Assessment form MR58, identify the recommended
risk prevention strategies relating to falls.
Match the following Falls Risk to the appropriate strategy.
Falls Risk Assessment Strategy
Greater than 1 fall in previous six months Leave bed and chair at correct height
Impaired vision Ensure appropriate aid is available
Poor balance Medical assessment for loss of consciousness
Uses walking aid Safe footwear
Generalised muscular weakness Ensure spectacles are within reach
Question 3 (marked out of 1- 1 mark for correctly chosen answer)
Which of the following is a risk factor related to the care of a person who is immobile and on
bedrest?
a) Increased risk of pneumonia and lung infections
b) Increased insulin requirements for carbohydrate metabolism
c) Loss of appetite from reduced activity, depression, boredom and illness
d) Weight loss and malnutrition from inadequate intake of nutrients
e) All responses are cor
5/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 6 (marked out of 3- 1 mark for correctly chosen answer)
You showered Mr. Smith this morning and noticed that he has a red area on his sacrum.
A) According to recording and reporting requirements, to whom do you report this? Select
the correct answer from the drop down box. (Registered Nurse, MO, physiotherapist)
B) According to recording and reporting requirements do you need to document this in the
patient’s progress notes? (YES/NO)
C) According to recording and reporting requirements which fundamental of care heading on
Mr. Smith’s care plan is the appropriate place to document this change? (mobility,
nutrition/hydration, comfort/pain, skin integrity)
Question 7 (marked out of 1- 1 mark for correctly chosen answer)
The Department of Health outline a process for conducting a case conference/meeting. This
process includes the requirements for recording and reporting in relation to case
meetings/conferences. All of the following requirements are essential EXCEPT…
Select one (1) item from the list below that does NOT apply:
Report on the patient’s care needs; and
Discuss and record outcomes to be achieved
Invite all members of the team to attend the meeting/conference
Report whether previously identified outcomes have been achieved
Record tasks that need to be undertaken to achieve these outcomes, and who tasks are
allocated to
Record the details of the meeting/conference (date, duration, names of participants) and
all matters discussed by the team; and
Place a copy of that record in the patient’s medical records.
Question 8 (marked out of 4- 1 mark for correctly chosen answer)
The person you are looking after has acute pain. From the list below select the four (4) appropriate
nursing interventions to assist in managing this person’s pain
Application of heat or cold according to organisational policy
Provide adequate analgesic medications
Regularly assess the person’s pain using appropriate pain score tool
Positioning of the person to promote physical comfort
Offer pain relief only if pain score is above 5 out of 10
Provide analgesia when the person requests it
Encourage movement to increase muscle warmth and reduce pain
6/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 9 (marked out of 2- 1 mark for correctly chosen answer)
What are two (2) nursing interventions that you can educate a person on that will have a positive
impact on their respiratory status?
Select one:
a- Core strength exercise
b- Passive and active limb exercises
c- Deep breathing and coughing exercises
d- Moving into a more upright position
Question 10 (marked out of 1- 1 mark for correctly chosen answer)
A person with a mental health condition may be admitted to a health care facility to manage risk
and alleviate distress.
Identify the risk/s associated with the episodic care of a person with a mental health condition.
a. Compromised safety of staff
b. Compromised safety o
7/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 13 (marked out of 9- 1 mark for correctly chosen answer)
For each of the items listed in the first column mix and match box the actual and potential nursing
care that could be implemented to meet a person’s needs.
Person’s need Actual and potential nursing care
Hygiene Correctly made bed that is clean and not
wrinkled
Toileting Regular position changes
Elimination needs Bed bath (sponge) and teeth brushing
Continence management Range-of-motion exercises
Physical comfort Assist with bedpan
Sleep disturbances Sheath/condom draining device, disposable
pads
Immobility Breathing exercises
Respiration Bowel regime and completing a Bristol stool
chart
Circulation Dark and quiet environment and restricting
visitors
Question 14 (marked out of 4- 1 mark for correctly chosen answer)
For each of the actual and potential nursing care listed in the first column, mix and match the
corresponding actions that could be implemented to meet the person’s oral hygiene needs.
Actual and potential nursing care Actions
Assisting a client to brush their teeth Place paper towel in bowl/basin to prevent
breakage during cleaning.
Assisting a client with the care of their
dentures
Correct technique to be used to avoid damage
to gums when cleaning between teeth.
Performing mouth care using alcohol free
mouth wash
Offer the opportunity for this to occur after
meals and in the evening
Assisting a client with interdental cleaning Provided regularly for people who are taking
oral food or fluids.
8/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 15 (marked out of 1- 1 mark for correctly chosen answer)
Risk prevention strategies for maintaining skin integrity and pressure area care include:
Select one:
a- a - use of skin and pressure risk assessments on clients who are bedridden only
b- re-positioning every eight-hours for high-risk clients
c- use of pressure-relieving devices which negates the need for re-positioning
d- consistent use of skin and pressure injury risk assessments
Question 16 (marked out of 3- 1 mark for correctly chosen answer)
‘A sensory deficit is impaired reception, perception, or both, of one or more senses’ (Koutoukidis
et al, 2017) and often involves the person requiring an aid such as a hearing aid or eye glasses.
From the list below, select three nursing considerations when meeting the needs of a person with
sensory deficits who requires a personal aid.
Select one or more:
a. Ensure the aid is for the correct person
b. Ensure the aids are a correct fir
c. Ensure aids are wiped clean with tissues or paper towelling
d. Ensure aids are put away correctly when not in use
Question 17 (marked out of 4- 1 mark for correctly chosen answer)
For each of the sensory deficits listed in the first column mix and match the actual and potential
nursing care that could be implemented to suit the person’s needs.
Sensory Deficit Actual and potential nursing care
Hearing impairment Assess and maintain mouth moisture through 2 hourly
mouth care
Vision impaired Use non-verbal cues to help convey meaning
Hypogeusia Discuss with the person which foods are the most taste
appealing
Parosmia Describe the meal referring to the plate as a clock face
9/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 18 (marked out of 16- 1 mark for correctly chosen answer)
Choose the correct words to complete the following paragraphs related to actual and potential
nursing care when assisting a person with teeth brushing.
oral plaque invisible fluoride
taste bacteria tongue two
gums toothbrush Brushing three
enamel teeth dry rinsed
Poor [ ] hygiene allows the [ ] in dental plaque to produce acids and other substances
which damage teeth, gums and surrounding bone.
[ ] is the most effective and economical method of physically removing dental [ ]
which forms continuously and begins as an [ ] film that sticks to all surfaces of the teeth and
or dentures, gums and tongue. Teeth, [ ] and tongue should be brushed [ ] times a day using a
soft toothbrush. Brushing the [ ] can improve an older person’s [ ] and hence
enjoyment of food.
Using a pea-size amount of [ ] toothpaste when brushing [ ] is recommended as it
protects natural teeth by remineralising and strengthening tooth [ ]. Following brushing, the
[ ] should be [ ] thoroughly and stored in a [ ] place. A toothbrush should be
replaced every [ ] months.
Question 19 (marked out of 1- 1 mark for correctly chosen answer)
Which of the following statements relating to actual and potential nursing care for alcohol-free
mouthwashes is correct:
Select one:
a. use as a replacement for regular oral hygiene routine
b. advise the person to spit out and not swallow the mouthwash
c. ensure the person is assisted into the supine position
d. advise the person to swish for 5 minutes for the mouthwash to be effective
Question 20 (marked out of 1- 1 mark for correctly chosen answer)
Which of the following statements relating to actual and potential nursing care for interdental
cleaning is correct:
Select one:
a. Use dental floss, an interdental brush or a toothbrush
b. Use a gentle back and forth motion, being careful around the gum line
c. Offer the client a toothpick to remove any food particles from between teeth
d. Use a circular motion to effectively remove the plaque from between the teeth
10/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 21 (marked out of 1- 1 mark for correctly chosen answer)
An increased but unpredictable risk of malnutrition is associated with hospitalisation.
Undertaking a thorou
11/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 24
You are caring for 68-year-old Mrs. Collins who has dementia and has been hospitalised.
What is the main risk related to her altered cognitive status?
a. increased risk of falls
b. increased risk for constipation
c. increased risk of aspiration pneumonia
d. none of the answers are correct
Question 25 (marked out of 1- 1 mark for correctly chosen answer)
Mrs. Collins has altered cognitive function related to her dementia and this needs to be taken into
consideration when planning her care.
From the list below choose the three (3) most appropriate nursing actions you would take to assist
a person with altered cognitive function
Break the task down into small steps
Allow Mrs. Collins to perform as much of the task as able
Give her time and do not rush
Give Mrs. Collins a number of instructions at once to get the task done quickly
Leave Mrs. Collins alone in the shower to reduce anxiety
Encourage Mrs. Collins to complete ADL’s quickly
Provide Mrs. Collins with a wide range of choices to encourage participation
Question 26 (marked out of 2- 1 mark for correctly chosen answer)
You are caring for a 68-year-old woman Mrs. Collins, who has dementia, she independently
mobilises around the ward. Mrs. Collins is easily agitated and often non-compliant with care. You
will need to assist her with morning hygiene and grooming (dressing) requirements, including oral
hygiene (she has top and bottom dentures).
List two (2) reasons why attending Mrs. Collins hygiene and grooming needs regularly is important
to her health
Question 27 (marked out of 4- 1 mark for correctly listed answer)
You are caring for Mrs. Collins, a 68-year-old woman who has dementia. Mrs. Collins mobilises
independently but requires assistance with her morning hygiene, dressing and grooming
requirements. She has top and bottom dentures. She is easily agitated and often non-compliant
with care.
List four (4) strategies that you would implement to promote a safe environment for Mrs. Collins
as you attend to her ADL’S.
Your answer must include correct in-text referencing and your full reference list provided in your
response to the last question of this assessment task.
12/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 28 (marked out of 6- 1 mark for correctly listed answer)
From the list below select the six (6) risks that are associated with post-operative care.
Wound Infection
Thrombophlebitis
Haemorrhage
Drowsiness
Pain
Nausea and vomiting
Incontinence
Diarrhoea
Paralysis
Depression
Headache
Question 29 (marked out of 7- 1 mark for correctly listed answer)
Mr. Harris has now been diagnosed with a Left-sided Cerebrovascular Accident (CVA), which has
left him with significant right-sided weakness, sensory loss in his right leg, urinary incontinence
and dysphagia.
Due to his dysphagia, Mr. Harris is allowed thickened fluids only, resulting in a fluid and nutritional
deficit.
Select the seven (7) appropriate nursing interventions to encourage Mr. Harris to increase his
nutritional intake and his oral fluid intake.
Offer Mr. Harris his preferred beverages
Ensure fluids are positioned within Mr. Harris’s reach
Offer Mr. Harris his preferred meal options
Facilitate meals times becoming a pleasurable experience
Educate Mr. Harris about the reason he is on thickened fluids
Give Mr. Harris encouragement and positive reinforcement
Ensure food and fluid are at preferred temperatures
Ensure meals are eaten quickly as you are very busy
Offer Mr Harris. Water at frequent intervals
Ensure privacy and independence by allowing Mr. Harris to eat alone
Ensure food is placed on the affected side of the mouth
Position Mr Harris. In a supine position with pillow to support to eat and drink
Ensure his thickened tea is cold before offering
Question 30 (marked out of 3- 1 mark for correctly listed answer)
Mr. Harris has been diagnosed with a Left-sided Cerebrovascular Accident (CVA), which has left
him with urinary incontinence and dysphagia.
Choose and circle the correct answer -
CHOOSE THE CORRECT WORDS TO COMPLETE THE FOLLOWING SENTENCES:
Urinary incontinence is a [symptom/underlying medical condition].
Dysphagia is a [symptom/underlying medical condition].
A Cerebrovascular accident (CV is a [symptom/underlying medical condition].
Question 31 (marked out of 5- 1 mark for correctly listed answer)
Mr. Harris does not want to get out of bed. This puts him at risk of developing a venous
thromboembolism, an umbrella term that includes deep vein thrombosis and a pulmonary
embolism.
For each of the statements below, select true or false.
a. A risk factor for developing a deep vein thrombosis is that the thrombus can detach from
the site and migrate via the blood stream to the vital organs including the brain
TRUE/FALSE
b. A risk factor related the development of a deep vein thrombosis is that perfusion to the
associated limb will be decreased
TRUE/FALSE
c. Pulmonary emboli are the leading cause of preventable deaths in the acute hospital setting
TRUE/FALSE
d. Prolonged immobility is a risk factor associated with pulmonary embolism and the
development of deep vein thrombosis
TRUE/FALSE
e. There is a decreased risk of developing a deep vein thrombosis post-operatively
TRUE/FALSE
Question 32
When assisting a person with their ADLs, it is important to identify risks associated with the
presence of morbidity.
Mix and match each of the statements below to the morbidity that it relates to
Heart Failure getting the person out of bed to shower with
shortness of breath will exacerbate respiratory
distress
Cerebral Vascular Accident do not lie flat during ADL’s as person will
become short of breath
Asthma laying a person on their affected side while
attending to ADL’s may cause pressure injuries
14/14
TAFE SA Student Written Assessment Version 3.0 ©TAFE SA
RTO CODE 41026 | CRICOS 00092B
Question 33 (marked out of 2- 1 mark for correctly listed answer)
You are caring for Mr. Lewis, a 42-year-old male who has returned to your ward following a
laminectomy. He has been advised to rest in bed for 24 hours, wear anti-embolic stockings and
keep the Sequential Compression Device (SCD) insitu during this time. He is able to roll over in
bed using the technique that he has been shown. Although Mr. Lewis has been educated in the
risks associated with having a laminectomy, he is non-compliant with his advised medical
treatment.
List two (2) potential risks to Mr. Lewis related to his non-compliance?