P2 FUNDA RLE RATIO 11-20 CHECK FOR UNDERSTANDING P2 RATIONALIZATION ACTIVITY 11

1. A patient’s room should be maintained at which temperature range? A. 20° and 24° C (68° and 73.8° F) B. 20° and 23° C (68° and 73.4° F) C. 19° and 22° C (66° and 73.4° F) D. 20° and 23° C (68° and 73.4° F) Answer: B – Depending on age and physical condition, maintain the room temperature between 20° and 23° C (68° and 73.4° F). 2. After making the bed of a patient, which of the following should you do? Select all that apply. A. Return it to the lowest horizontal position B. Return it to the lowest vertical position C. Verify that the wheels are not unlocked D. Verify that the wheels are unlocked Answer: A, C – After making a bed, return it to the lowest horizontal position and verify that the wheels are locked to prevent accidental falls when the patient gets in and out alone. 3. To avoid bending and stretching over the mattress, what should a nurse do? A. Perform stretching exercises B. Raise the bed to the appropriate height C. Ask the patient to get out of the bed D. Assist the patient out of bed Answer: B – Always raise the bed to the appropriate height before changing linen so you do not have to bend or stretch over the mattress. 4. A nursing attendant is removing the used linens from a room that has just been vacated, all of the following are correct should be done except: A. Shake the linen. B. Do not place the soiled linen on the floor C. Place the soiled linen on linen bags D. None of the above Answer: A – To avoid air currents that spread microorganisms, never shake the linen. 5. You are removing the soiled linens of a patient which principle should be observed: A. Sterile technique B. Medical asepsis C. Surgical asepsis D. Concept of asepsis Answer: B – When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform. 6. As you went to check on your patient, you saw her significant other remove the used bedpan from the overbed table to facilitate serving meals. What should you do? Select all that apply. A. Let the significant other do her own thing B. Ask if the bedpan has been used, if not it causes no problem C. Instruct the significant other not to place the bedpan or urinal in the overbed table D. Clean the over-bed table with antiseptic cleaner Answer: C, D – Do not place the bed pan or urinal on the over-bed table. When changing bed linen, follow principles of medical asepsis by keeping soiled linen away from the uniform. 7. How can a ventilation system be classified as effective? A. Effective ventilation systems are mostly costly. B. All effective ventilation systems work in the same manner and are all effective. C. Stale air and foul odors are not lingering in a room. D. All of the above Answer: C – An effective ventilation system keeps stale air and odors from lingering in a room. 8. After a patient uses a urinal, the nurse-in-charge discards the urine and places it inside the toilet. What would you perform differently that is in accordance with the protocols? Select all that apply. A. Measure the urine output even if in not strict I&O monitoring. B. Place the urinal at the bedside table to offer accessibility and convenience. C. Rinse the urinal after each use. D. All the actions done by the nurse is in accordance with the guidelines. Answer: A & C – Always measure urine output quantitatively to document accurate data and empty and rinse commodes, bedpans, and urinals promptly after each use. 9. Which of the following is incorrect about bed making? A. Changing linens are done only in the morning. B. Changing lines is usually done in the morning after the patient’s bath. C. Changing linens are done as needed (e.g soiled, wet) D. B & C Answer: A – Both B & C are correct. 10. A patient has an ongoing Nicardipine drip who is placed on an IV infusion pump. The device used emits a beeping sound as there is no mute function. What should you do as a nurse? A. Stop the device as it causes anxiety to the patient. B. Stop the device and and document the the incident. C. Inform the patient that the sound emitted by the device is normal. D. None of the above. Answer: C – Infusion a pump usually emit beeping sounds and is normal. RATIONALIZATION ACTIVITY 12 WORD DESCRIPTION/FUNCTION DRAWSHEET A drawsheet can aid moving the patient in bed. FLOOR The floor is heavily contaminated. GLOVES Hand hygiene and PPE prevent the spread of microorganisms. HAMPER Placing linens directly into the hamper helps prevent the spread of microorganisms. LOOSENING Loosening linens over the patient’s feet gives more room for movement. MITER This provides for a neat appearance. PILLOWCASE Open each pillowcase in the same manner as you opened other linens. SHAKING Opening linens by shaking them causes organisms to be carried on air currents. WRINKLES Wrinkles and creases in the linens are uncomfortable to lie on. RATIONALIZATION ACTIVITY 13 1. These are quick and efficient way of monitoring a patient's condition or identifying problems and evaluating his or her response to intervention. A. Vital signs B. Body temperature C. Respiratory rate D. All of the above Answer: A – Vital signs are are quick and efficient way of monitoring a patient's condition or identifying problems and evaluating his or her response to intervention. 2. This occurs because heat-loss mechanisms are unable to keep pace with excessive heat production. A. Heat exhaustion B. Heat stroke C. Hyperthermia D. Fever or pyrexia Answer: D – Fever occurs because heat-loss mechanisms are unable to keep pace with excessive heat production. 3. A patient complains in the ER that her axillary temperature rises and falls for the last two days but has never returned within the normal range. What is this pattern called? A. Sustained B. Intermittent C. Remittent D. Relapsing Answer: C – Remittent fever is where the temperature spikes and falls without a return to acceptable temperature levels. 4. As it was endorsed, the newly admitted patient has lesions on her left axilla. How will you measure her temperature? A. Do not measure her temperature, document the reason, inform the health care provider B. Measure her temperature, inform her that it will be quick C. Assess the right axillar for lesions, if none, use that site to measure the temperature. D. Proceed with measuring the temperature orally. Answer: C – Check the right axilla; Presence of skin lesions may alter local temperature or area may be painful to touch. 5. The thermometer measured a patient’s axillary temperature at 38.9oC. What will you do? A. Document at the appropriate log B. Document, inform patient & give paracetamol C. Document, inform patient & cover the patient with thick blankets D. Document, inform patient & offer tepid sponge bath Answer: D – Body temperature regulation; is bathing a patient with a cool cloth increases conductive heat loss. 6. Using this site for measuring the temperature is prescribed as it is reliable for stable term and preterm infants, however, not recommended for detecting fever: A. Oral B. Axillary C. Temporal artery D. Skin Answer: B – Prescribed as it is reliable for stable term and preterm infants, however, not recommended for detecting fever. 7. This site for measuring temperature is sensitive to core temperature changes but inaccuracies are reported due to incorrect positioning of the device: A. Temporal Artery B. Skin C. Rectal D. Tympanic membrane Answer: D – Sensitive to core temperature changes but inaccuracies are reported due to incorrect positioning of the device. 8. Refers to a temperature alteration where an elevated body temperature is related to the inability of the body to promote heat loss or reduce heat production: A. Heat exhaustion B. Heat stroke C. Hyperthermia D. Fever or pyrexia Answer: A - Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. 9. This is described as the involuntary body response to temperature differences in the body: A. Basal metabolic regulation B. Radiation C. Shivering D. Diaphoresis Answer: C - Shivering is an involuntary body response to temperature differences in the body. 10. It is a fever pattern that is regarded for fever spikes interspersed with usual temperature levels; returns to acceptable value at least once in 24 hours. A. Sustained B. Intermittent C. Remittent D. Relapsing Answer: B – Fever spikes interspersed with usual temperature levels; returns to acceptable value at least once in 24 hours. RATIONALIZATION ACTIVITY 14 1. It is described as the movement of gases in and out of the lungs: A. Respiration B. Ventilation C. Diffusion D. Perfusion Answer: B – is described as the movement of gases in and out of the lungs 2. A nurse knows not to let the patient know that her respirations are being assessed for what rationale? A. Patients should be informed of all procedures done B. Provide inaccurate results C. Alter rate and depth of breathing D. A and B Answer: D – An inaccurate result can be obtained as patients who are aware of of the assessment can alter the rate and depth of breathing. 3. Which of the following factors result to increased respiratory rate and depth? Select all that apply. A. Exercise B. Acute pain C. Anxiety D. Smoking