NUR 242 EXAM 1

NUR 242 EXAM 1

isfwanfwRNfwworkingfwatfwafwrehabilitationfwcenterfwandfwwitnessesfwafwnursefwaidfwstrugglin
gfwtofwliftfwandfwrepositionfwanfwelderly,fwbedfwriddenfwpatient.fwShefwexplainsfwtofwthefwnurs
efwaidefwthatfwtherefwisfwafwNofwLiftfwPolicyfwinfwplacefwinfwthefwestablishment.fwWhatfwdoesfwt
hisfwpolicyfwentail?fw-fwanswer--Thefwconceptfwoffwafwno-
liftfwpolicyfwisfwafwpledgefwfromfwadministratorsfwthatfwproperfwequipment,fwadequatelyfwma
intainedfwandfwinfwsufficientfwnumbers,fwwillfwbefwavailablefwtofwcarefwprovidersfwtofwreducef
wthefwrisksfwassociatedfwwithfwmanualfwpatientfwhandling



Immobilityfweffectsfwmultiplefwbodyfwsystems.fwWhatfwarefwsomefwinterventionsfwthatfwyouf
wcanfwimplementfwtofwdecreasefwthesefweffects?fwSelectfwallfwthatfwapply.



A.fwUtilizingfwwafflefwmattressfwtofwreducefwthefwneedfwforfwrepositioning
B.fwTeds/SCDs
C.fwRubbingfwreddenedfwareas
D.fwLimitingfwfluidfwintake
E.fwROMfwexercisesfw-fwanswer--Answer:fwBfwandfwE

Rational:fw
-
Afwisfwincorrectfwbecausefwregardlessfwoffwimplementedfwmattress,fwpositioningfwshouldfw
befweveryfw2fwhours
-
Cfwisfwincorrect.fwYoufwshouldfwnotfwrubfwatfwreddenedfwareas.fwThisfwincreasesfwthefwriskfwf
orfwskinfwbreak.
-
Dfwisfwincorrect.fwYoufwshouldfwencouragefwproperfwhydrationfwtofwpromotefwwellfwhydrate
dfwandfwhealthyfwskin.

TruefworfwFalse:fwNursesfwshouldfwdofwskinfwassessmentsfwoncefwafwweek.fw-fwanswer--
False

Rational:fwNursesfwshouldfwdofwfullfwskinfwassessmentsfwafwminimumfwoffwoncefwperfwshift.

AfwptfwgoesfwtofwthefwERfwforfwswellingfwandfwpainfwinfwherfwrightfwcalf.fwThefwPTfwstatesfwthatf
witfwoccurredfwafterfwshefwaccidentallyfwcutfwherself.fwBasedfwonfwherfwsymptoms,fwwhatfwsk

infwconditionfwmightfwthefwnursefwsuspectfwthefwpatientfwhas?fw-fwanswer--Cellulitis.

Cellulitisfwisfwinflammationfwoffwthefwskinfwandfwsubqfwtissue.

PtfwAfwisfwadmittedfwfromfwafwnursingfwhomefwwithfwafwstagefw3fwpressurefwulcer.fwWhenfwcr
eatingfwhisfwplanfwoffwcare,fwwhofwelsefwwouldfwbefwinvolvedfwbesidesfwthefwprimaryfwcarefw
physician?fw-fwanswer--
Woundfwcarefwnurse,fwDietician,fwPhysicalfwtherapist.fwOTfwcanfwalsofwbefwincluded,fwhow
everfwtheyfwdealfwmorefwwithfwfinefwmotorfwskills.

, Anfw85fwyearfwoldfwwomanfwisfwadmittedfwtofwthefwhospital.fwWhenfwdoingfwthefwinitialfwasse
ssment,fwwhatfwarefwsomefwfactorsfwthatfwyoufwknowfwputfwherfwatfwriskfwforfwpressurefwinjuri
es?fw-fwanswer---iffwthefwptfwisfwimmobile
-iffwthefwptfwisfwincontinent
-iffwthefwptfwhasfwcomorbiditiesfwsuchfwasfwdiabetesfworfwPVD
-iffwthefwptfwisfwmalnourishedfworfwdehydrated
-iffwthefwptfwsuffersfwfromfwdecreasedfwsensoryfwperception

Thefwnursefwnoticesfwafwlocalizedfwredfwareafwthatfwisfwnonblanchablefwonfwthefwthefwpatient
'sfwcoccyx.fwWhatfwstagefwpressurefwinjuryfwisfwthisfwrecognizedfwas?fw-fwanswer--Stagefw1

Stagefw1fwpressurefwinjuryfwmeansfwthefwskinfwisfwintactfwwithfwafwlocalizedfwareafwoffwnonbl
anchablefwerythemafw(fancyfwwordfwforfwredness).

Afwptfwasksfwyoufwwhyfwwhatfwhefweatsfwhasfwanythingfwtofwdofwwithfwwoundfwhealing.fwWhat
fwisfwyourfwresponse?fw-fwanswer--

Successfulfwhealingfwoffwpressurefwinjuriesfwdependsfwonfwadequatefwintakefwoffwcaloriesfw
protein,fwvitamins,fwmineralsfwandfwwater.

Afterfwreceivingfwshiftfwreport,fwthefwnightfwnursefwlooksfwatfwthefwlabfwvaluesfwforfwafwpatientf
wwithfwcellulitis.fwWhatfwabnormalfwlabfwvaluesfwmightfwyoufwsee?fw-fwanswer---WBCfw-

fwelevated

-Creatinine-fwelevated
-Bicarbonate-fwlow
-Albumin-fwlow
-Calcium-fwlow

Whatfwpainfwratingfwscalefwmightfwyoufwusefwforfwafwchildfworfwafwnonverbalfwpatient?fw-
fwanswer--WongfwBaker-FacesfwScale



Whenfwassessingfwafwpt'sfwpain.fwHefwtellsfwyoufwthatfwthefwpainfwcomesfwandfwgoes.fwWhatf
wpartfwoffwthefwpainfwassessmentfwisfwhefwdescribing?



A.fwQuality
B.fwIntensity
C.fwOnsetfwandfwDuration
D.fwLocationfw-fwanswer--C.fwOnsetfwandfwDuration

Whenfwexplainingfwtofwafwptfwwhatfwanfwintraspinalfwanalgesicfwthefwptfwstatesfw"Sofwthefwme
dicationfwwillfwbefwgivenfwtofwmefwthroughfwthefwIVfwinfwmyfwarm."fwHowfwwouldfwyoufwcorrect
fwhim?fw-fwanswer--

instraspinalfwanalgesicsfwarefwdeliveredfwintofwthefwepiduralfwspacefwoffwthefwspine,fwalsofw
knownfwasfwthefwsubarachnoidfwspace.

WhenfwadjustingfwafwTENsfwmachinefwonfwafwpatient,fwhowfwdofwyoufwknowfwthefwconductio
nfwoffwelectricityfwhasfwreachedfwafwtherapeuticfwlevel?fw-fwanswer--
Thefwpatientfwwillfwverbalizefwfeelingfwafwsensationfwoffwpinsfwandfwneedles.