NUR_242_Exam_1_Study_Guide
1. Patricia is an RN working at a rehabili- The concept of a no-lift policy is a pledge from
tation center and witnesses a nurse aid administrators that proper equipment, ade-
struggling to lift and reposition an elderly, quately maintained and in sufficient numbers,
bed ridden patient. She explains to the will be available to care providers to reduce
nurse aide that there is a No Lift Policy in the risks associated with manual patient han-
place in the establishment. What does this dling
policy entail?
2. Immobility effects multiple body systems. Answer: B and E
What are some interventions that you can
implement to decrease these effects? Se- Rational:
lect all that apply. -A is incorrect because regardless of imple-
mented mattress, positioning should be every
A. Utilizing waffle mattress to reduce the 2 hours
need for repositioning -C is incorrect. You should not rub at red-
B. Teds/SCDs dened areas. This increases the risk for skin
C. Rubbing reddened areas break.
D. Limiting fluid intake -D is incorrect. You should encourage prop-
E. ROM exercises er hydration to promote well hydrated and
healthy skin.
3. True or False: Nurses should do skin as- False
sessments once a week.
Rational: Nurses should do full skin assess-
ments a minimum of once per shift.
4. A pt goes to the ER for swelling and pain Cellulitis.
in her right calf. The PT states that it oc-
curred after she accidentally cut herself. Cellulitis is inflammation of the skin and subq
Based on her symptoms, what skin condi- tissue.
tion might the nurse suspect the patient
has?
1/6
, 5. Pt A is admitted from a nursing home with Wound care nurse, Dietician, Physical thera-
a stage 3 pressure ulcer. When creating his pist. OT can also be included, however they
plan of care, who else would be involved deal more with fine motor skills.
besides the primary care physician?
6. An 85 year old woman is admitted to the -if the pt is immobile
hospital. When doing the initial assess- -if the pt is incontinent
ment, what are some factors that you -if the pt has comorbidities such as diabetes
know put her at risk for pressure injuries? or PVD
-if the pt is malnourished or dehydrated
-if the pt suffers from decreased sensory per-
ception
7. The nurse notices a localized red area that Stage 1
is nonblanchable on the the patient's coc-
cyx. What stage pressure injury is this rec- Stage 1 pressure injury means the skin is in-
ognized as? tact with a localized area of nonblanchable
erythema (fancy word for redness).
8. A pt asks you why what he eats has any- Successful healing of pressure injuries de-
thing to do with wound healing. What is pends on adequate intake of calories protein,
your response? vitamins, minerals and water.
9. After receiving shift report, the night -WBC - elevated
nurse looks at the lab values for a patient -Creatinine- elevated
with cellulitis. What abnormal lab values -Bicarbonate- low
might you see? -Albumin- low
-Calcium- low
10. What pain rating scale might you use for Wong Baker-Faces Scale
a child or a nonverbal patient?
11. C. Onset and Duration
2/6
1. Patricia is an RN working at a rehabili- The concept of a no-lift policy is a pledge from
tation center and witnesses a nurse aid administrators that proper equipment, ade-
struggling to lift and reposition an elderly, quately maintained and in sufficient numbers,
bed ridden patient. She explains to the will be available to care providers to reduce
nurse aide that there is a No Lift Policy in the risks associated with manual patient han-
place in the establishment. What does this dling
policy entail?
2. Immobility effects multiple body systems. Answer: B and E
What are some interventions that you can
implement to decrease these effects? Se- Rational:
lect all that apply. -A is incorrect because regardless of imple-
mented mattress, positioning should be every
A. Utilizing waffle mattress to reduce the 2 hours
need for repositioning -C is incorrect. You should not rub at red-
B. Teds/SCDs dened areas. This increases the risk for skin
C. Rubbing reddened areas break.
D. Limiting fluid intake -D is incorrect. You should encourage prop-
E. ROM exercises er hydration to promote well hydrated and
healthy skin.
3. True or False: Nurses should do skin as- False
sessments once a week.
Rational: Nurses should do full skin assess-
ments a minimum of once per shift.
4. A pt goes to the ER for swelling and pain Cellulitis.
in her right calf. The PT states that it oc-
curred after she accidentally cut herself. Cellulitis is inflammation of the skin and subq
Based on her symptoms, what skin condi- tissue.
tion might the nurse suspect the patient
has?
1/6
, 5. Pt A is admitted from a nursing home with Wound care nurse, Dietician, Physical thera-
a stage 3 pressure ulcer. When creating his pist. OT can also be included, however they
plan of care, who else would be involved deal more with fine motor skills.
besides the primary care physician?
6. An 85 year old woman is admitted to the -if the pt is immobile
hospital. When doing the initial assess- -if the pt is incontinent
ment, what are some factors that you -if the pt has comorbidities such as diabetes
know put her at risk for pressure injuries? or PVD
-if the pt is malnourished or dehydrated
-if the pt suffers from decreased sensory per-
ception
7. The nurse notices a localized red area that Stage 1
is nonblanchable on the the patient's coc-
cyx. What stage pressure injury is this rec- Stage 1 pressure injury means the skin is in-
ognized as? tact with a localized area of nonblanchable
erythema (fancy word for redness).
8. A pt asks you why what he eats has any- Successful healing of pressure injuries de-
thing to do with wound healing. What is pends on adequate intake of calories protein,
your response? vitamins, minerals and water.
9. After receiving shift report, the night -WBC - elevated
nurse looks at the lab values for a patient -Creatinine- elevated
with cellulitis. What abnormal lab values -Bicarbonate- low
might you see? -Albumin- low
-Calcium- low
10. What pain rating scale might you use for Wong Baker-Faces Scale
a child or a nonverbal patient?
11. C. Onset and Duration
2/6
