NUR 311 Midterm Exam 2025

How do you properly identify the client prior to assessment or administering care in the INPATIENT setting? - -patient name patient medical record number patient birth date How do you properly identify the client prior to assessment or administering care in the LTC (long term care) setting? - -patient name patient birth date visual picture of patient What are the steps for AIDET? - -acknowledge, introduce, duration, explanation, thank you What are 3 rationales for hourly rounding? - -address the 4 p's (pain, position, potty, personal effects); perform scheduled tasks; update whiteboard information What are the fall prevention interventions? - -bed in lowered/locked; nonskid footwear; orient patient with surroundings; place personal items within reach; bed/chair alarm; move patient to a room in sight What are the principles of body mechanics? - -correct body alignment; maintain balance; face the direction of movement; perform work at appropriate height; use mechanical lifts What are appropriate equipment and assistive devices for moving patients? - -gait belts; friction reducing sheets; transfer chairs; stand-assist and repositioning aids; powered full body lifts What are 3 expected outcomes when performing ROM? - -prevent muscle atrophy; strengthens muscles; maintains joint mobility Movement away from the center or median line of the body. - -abduction Movement towards the center or median line of the body. - -adduction Bending of a joint so that the angle of the joint diminishes - -flexion The return movement from flexion; the joint angle is increased - -extension Turning of the palm or foot downward or backward - -palm is pronation; foot is plantarflexion NUR 311 NUR 311 Process of turning on an axis; twisting or revolving - -rotation Turning the palm or foot upward - -Palm is supination; foot is dorsiflexion Extreme or abnormal extension - -hyperextension How do you measure/fit a client for use of a walker? - -handles at hip level; elbows flexed at 30 degrees How do you measure/fit a client for use of a cane? - -at waist height with elbows flexed at 30 degrees; position 4-12 inches forward How do you measure/fit a client for use of crutches? - -palm of the hand should fit between the top of the crutches and the armpit What are the recommended guidelines for moving and lifting patients when the client provides no assistance - -full body and 2 or more caregivers What are the recommended guidelines for moving and lifting patients when the client is able to partially assist and weighs LESS than 200lbs? - -friction reducing sheets and 2 to 3 caregivers What are the recommended guidelines for moving and lifting patients when the client is able to partially assist and weighs GREATER than 200lbs? - -friction reducing device and at-least 3 caregivers What are the components of ABCs? - -hand hygiene; provide privacy; explain procedure; raise bed to working height What are the components of ZYCs? - -position patient comfortably; raise side rails; bed locked at lowest position; call light within reach; clutter free room; hand hygiene; documentation What education should be provided to a client and his/her family members regarding seizure precautions? - -prevent aspirations, protect from injury; turn on side What actions should you take if a seizure occurs? - -- remain with client; call for assistance - do not restrain client or place anything in mouth - protect the head and turn client on side - loosen tight clothes - if occurs while ambulating or sitting in chair, cradle heard or provide a cushion or support for protection against head injury - apply oxygen and suction oral airway as needed - administer anticonvulsant or anti-epileptic NUR 311 NUR 311 What type of restraints should be tried first? - -least restrictive What is the order of restraints from least to most restrictive? - -Side rails - mitts; elbow immobilizer; enclosure bed; soft belt - soft limb - waist/vest - 4 point soft hard limb velcro or leather What are 4 alternatives to applying restraints? - -reduce stimulation; ask family or significant others to stay with patient; place unstable patient in an area where they are easily visible; asses for pain and treat Where on the bed should the restraints be tied? - -bed frame List assessment needs for the patient in restraints - -check every 2 hours for skin integrity; continuous need for them; range of motion; circulation; offer fluid nutrition and toileting every 2 hours What is the purpose of a bath? - -cleanliness and grooming, physical and psychological well being, gentle friction stimulates circulation, complete skin assessment, and establish a therapeutic relationship What is the preferred method of bathing for a client who is ambulatory and tolerates activity? - -shower or tub bath What is the preferred method of bathing a client with physical limitations, such as fatigue or limited ROM? - -bed bath What should you encourage or assist the client with prior to bathing to lessen the likelihood that the bath will be interrupted? - -toileting What is considered to be a comfortable working height for providing a bed bath? - elbow height as it prevents back and muscle strain When providing a patient bed bath, what area of the body will you cleanse first and last? why? - -first: face (least contaminated) last: perineal area (most contaminated) What is the most important concept and technique regarding perineal care? - -clean least to most contaminated; use a clean portion of the wash cloth with each stroke; ensure area is dry after washing What is the purpose of oral care? - -prevent dental gingivitis and dental caries; improve patient self-image; and limits pathogen growth in mouth What position should you place the patient in prior to providing oral care? - -sitting up if conscious; side lying if unconscious NUR 311 NUR 311 What age should a person begin implementing oral hygiene? - -once you get your first tooth How do you clean the oral cavity of a client who wears dentures? - -with a soft bristle brush and paste to clean the gums, mucous membrane and tongue How do you clean dentures? - -use gauze to remove and assess for redness; clean dentures in a towel lined sink using brush, paste and denture cleaner; store in a labeled cup with cold water; clean gently and throughly How should you store cleaned dentures that are not immediately replaced in the clients mouth? - -in a denture container with cold water and label the container and place on bed-side table How do you check the gag reflex in an unresponsive client? - -place tongue depressor or blade towards the back of the tongue Why is it important to assess whether the unconscious patient wears contact lenses? - can lead to further damage or infection What is most important to asses prior to shaving a client? - -if they are taking any anticoagulants, received an antithrombolytic agents, or have a low platelet count. What shaver is usually recommended when the patient is receiving anticoagulant therapy? - -electric razor You have determined it is safe to shave your client's facial hair with a razor. What is the first nursing action? - -press warm cloth on area to moisten skin and soften hair Why is nail care important? - -prevent pain and infection; can be dangerous to patient; can affect walking/mobility; and can prevent nails from breaking Why is it important to make sure the bottom sheet is tightly fitted to the mattress and the draw sheet tucked securely under the mattress? - -skin integrity (friction and shearing) and patient comfort What is the purpose of the draw sheet? How can you tell if it is correctly positioned on the bed? - -aid in moving patient in bed, reduces friction. location - shoulders to mid thigh location What is the purpose of toe pleats? - -more room for movement, allow for better circulation, and prevent sores NUR 311 NUR 311 What is the appropriate way to dispose of soiled linens? - -roll them up tightly in bottom sheet; dispose directly into laundry/linen basket; don't let them touch your uniform or place them on furniture What is the difference between an open and closed bed? - -Open: occupied bed with sheets fan-folded or pie-folded Closed: unoccupied bed where bed is completely made and spread covers bed to prevent dust and dirt from getting in sheets When is it appropriate to use soap and water to clean your hands? - -if hands are visibly dirty; before eating and after using restroom; if exposed to certain organisms such as anthrax, C-Diff or norovirus; if you come in contact with blood or bodily fluids When is it appropriate to use alcohol-based hand rub? - -if hands aren't visibly soiled or dirty What wound characteristics do you assess for? - -size, shape, drainage, tunneling, smell, open or closed, depth How do you measure the depth of your patients wound? - -sterile applicator at 90 degrees pressed in and mark with fingers and then put next to ruler and measure If your patient is in pain before you begin the dressing change, what is the most appropriate nursing intervention? - -administer analgesic and wait 30 minutes or until pain score decreases before continuing What is the correct solution to use if the dressing is stuck to the wound? - -normal saline What considerations should be made for the sensitive skin of older patients? - montgomery straps; rolled gauze; skin barrier; paper tape What is the appropriate direction used to clean a wound? - -top to bottom, center to outside At what point do you know a wound has been adequately irrigated? - -when the solution runs clear When preparing a sterile field, why should the work area be waist level or higher? - prevent contamination, bacteria tends to settle and work area must be within sight What should the nurse do when a part of the sterile field becomes contaminated? - discard and start over When the nurse realizes a supply is missing after setting up the sterile field, what actions should be taken? - -call for help, don't leave sterile field unattended NUR 311 NUR 311 How should a commercially prepared sterile kit or tray be opened? - -top most flap away from the body, then the side flaps away from the body and then last flap towards yoy How high above the surface of a sterile field should items be held before being dropped onto the field? - -6 inches Why do we need to avoid splashing liquid onto a sterile field? - -moisture contaminates a sterile field When do sterile gloves need to be replaced? - -when you tear/rip them or become contaminated or compromised. How should the inner package of sterile gloves be opened? - -top flap, bottom flap, side flaps When donning sterile glove, which hand is gloved first? - -dominate hand What should the nurse do when contamination occurs during the application of sterile gloves? - -discard gloves and open a new