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NUR 242 Exam 1 with correct answers
Patricia is an RN working at a rehabilitation center and witnesses a nurse aid struggling to lift and reposition an elderly, bed ridden patient. She explains to the nurse aide that there is a No Lift Policy in place in the establishment. What does this policy entail? - CORRECT ANSWERS ✔✔The concept of a no-lift policy is a pledge from administrators that proper equipment, adequately maintained and in sufficient numbers, will be available to care providers to reduce the risks associated with manual patient handling Immobility effects multiple body systems. What are some interventions that you can implement to decrease these effects? Select all that apply. A. Utilizing waffle mattress to reduce the need for repositioning B. Teds/SCDs C. Rubbing reddened areas D. Limiting fluid intake E. ROM exercises - CORRECT ANSWERS ✔✔Answer: B and E Rational: -A is incorrect because regardless of implemented mattress, positioning should be every 2 hours -C is incorrect. You should not rub at reddened areas. This increases the risk for skin break.
-D is incorrect. You should encourage proper hydration to promote well hydrated and healthy skin. True or False: Nurses should do skin assessments once a week. - CORRECT ANSWERS ✔✔False Rational: Nurses should do full skin assessments a minimum of once per shift. A pt goes to the ER for swelling and pain in her right calf. The PT states that it occurred after she accidentally cut herself. Based on her symptoms, what skin condition might the nurse suspect the patient has? - CORRECT ANSWERS ✔✔Cellulitis. Cellulitis is inflammation of the skin and subq tissue. Pt A is admitted from a nursing home with a stage 3 pressure ulcer. When creating his plan of care, who else would be involved besides the primary care physician? - CORRECT ANSWERS ✔✔Wound care nurse, Dietician, Physical therapist. OT can also be included, however they deal more with fine motor skills. An 85 year old woman is admitted to the hospital. When doing the initial assessment, what are some factors that you know put her at risk for pressure injuries? - CORRECT ANSWERS ✔✔-if the pt is immobile -if the pt is incontinent -if the pt has comorbidities such as diabetes or PVD
When assessing a pt's pain. He tells you that the pain comes and goes. What part of the pain assessment is he describing? A. Quality B. Intensity C. Onset and Duration D. Location - CORRECT ANSWERS ✔✔C. Onset and Duration When explaining to a pt what an intraspinal analgesic the pt states "So the medication will be given to me through the IV in my arm." How would you correct him? - CORRECT ANSWERS ✔✔instraspinal analgesics are delivered into the epidural space of the spine, also known as the subarachnoid space. When adjusting a TENs machine on a patient, how do you know the conduction of electricity has reached a therapeutic level? - CORRECT ANSWERS ✔✔The patient will verbalize feeling a sensation of pins and needles. Your pt verbalizes a pain of 2/10 and requests their dose of morphine. How would you educate your pt? - CORRECT ANSWERS ✔✔Morphine is an opioid analgesic used for moderate to severe pain. What is the most common side effect of analgesic use and how can we prevent it? - CORRECT ANSWERS ✔✔Constipation.
A high fiber diet, plenty of fluids, and stool softeners are prophylactic measures. The patient is undergoing surgery to fix a cleft palate. What type of surgery is this considered? - CORRECT ANSWERS ✔✔Constructive A biopsy is what type of procedure? - CORRECT ANSWERS ✔✔Diagnostic This type of surgery prolongs life but does not cure the underlying disease - CORRECT ANSWERS ✔✔Palliative A patient has received 10 mg of Morphine via IV 20 minutes ago and is noticeably groggy. The physician requests you witness the signature of his informed consent. How would you, as a patient advocate, proceed? - CORRECT ANSWERS ✔✔Informed consent should be received before patient is given any preop analgesics to ensure a clear state of mind. Side note: A nurse is not responsible for clarification of risks or procedure explanation. A nurse can witness signature. Pneumonia and Atelectasis are serious concerns post op. What are some things that we can encourage the patient to do to prevent these complications? - CORRECT ANSWERS ✔✔Incentive spirometry, coughing, and deep breathing
What is this a potential sign of? A.Infection B. Heavy blood loss C. These vitals are to be expected after a procedure - CORRECT ANSWERS ✔✔B Normal RBC Lab Values - CORRECT ANSWERS ✔✔Women: 4.2 to 5. million/uL Men: 4.7 to 6.1 million/uL Children: 4.6 to 4.8 million/uL A pt presents with muscle weakness, trouble walking, and a beefy red tongue. Based on these symptoms, what might we conclude the patient will be diagnosed with? - CORRECT ANSWERS ✔✔B-12 Deficiency What signs and symptoms might you suspect a patient exhibit if they were iron deficient? Select all that apply. a. weakness b. palor c. tachypnea d. fatigue e. beefy red tongue - CORRECT ANSWERS ✔✔Answer:
A, B, and D When caring for a patient with Sickle Cell Anemia, what are some nursing interventions you'll need to implement? - CORRECT ANSWERS ✔✔- Avoid extreme temperatures
- Keep room warm
- Encourage fluid intake -Encourage ROM
- Pain management Match the following infections with the precaution type A. Standard B. Droplet C. Airborne
- __ MRSA. 5. __ Measles
- __ TB 6. __ Varicella
- __ Influenza 7. __ Pneumonia
- __ Pediculosis 8 .__ Meningitis - CORRECT ANSWERS ✔✔A, C, B, A, C, C, B, B A pt is receiving a blood transfusion and breaks out in hives. What is the nurses first step? - CORRECT ANSWERS ✔✔Immediately stop the the transfusion and start normal saline
