NURS 20030 INTERVENTIONS FINAL REVIEW QUESTIONS WELL ANSWERED LATEST UPDATE 2026
Hygiene - Answers -remove dentures, glasses and hearing aids from meal tray
-inspect for skin breakdown when bathing
-outside of nurse's scope of practice to trim toe nails
-use electric razor for someone on anticoagulants and soft tooth brush (warfarin)
-line the sink with a towel when cleaning dentures
-turn head to side when performing oral care
- use only warm water for cleaning eyes (no soap)
- effleurage- relaxation massage technique
-diabetic patient don't put lotion between toes
-don't massage reddened areas
-turn patient every 2 hours
mobility - Answers -assistive device goes on strong side of patient
-if coarse crackles in lower lungs, auscultate in high fowlers
-if pt has an aspiration risk keep them in high fowlers
-prolonged bedrest increases the HR
-a pillow under extremities facilitates venous return
-sit pt up when they're on a bedpan
-foot boards can prevent foot drop
-hand boards prevent contractures
-abduction pillow is used for a pt who has had a hip replacement to keep ball in socket
-history of falls is number one indication of falls
-ALWAYS ASSESS PT FIRST
-weak leg and cane move together
-on stairs, stronger leg goes first
-contracture interfere with pt's normal alignment; keep that in mind when moving them
-use logrolling technique if pt has spinal problems or is overweight
four-point crutch walk - Answers can bear weight on all legs
three-point crutch walk - Answers can bear weight on one leg
two-point crutch walk - Answers pt must be able to bear at least partial weight on both legs
swing through crutch walk - Answers pt cannot bear any weight to legs
afferent nervous system - Answers conveys information to the CNS
efferent nervous system - Answers conveys a response from the CNS to the skeletal muscles via the
somatic nervous system
impact on immobility on function - Answers -increase cardiac workload
-decrease lung expansion
-retained secretions
-muscle atrophy
-contractures
-osteoporosis
-anorexia
-negative nitrogen balance
-impaired immunity
-pressure ulcers
-urinary stasis
-UTI
-renal calculi
-constipation
cardiopulmonary prevention - Answers -cough and deep breath
-increase fluids and activity
DVT prevention - Answers TEDs and SCDs
sterile technique - Answers -sterile bottle must be marked with date, time opened, and nurse's
initials
-must discard sterile solution 24-48hours after opening
-moisture contaminates a sterile field
, -sterile field must be above waist, never turn your back on a sterile field, outer 1 inch boarder is not
sterile
-provide pain medication before a dressing change
-cleans gloves to remove it, sterile gloves to change it
-label dressing with date,time, and initial
-wet to dry dressing is mechanical debridement
-Montgomery straps are the things that look like shoe laces and used for large abdominal wounds
that need dressing changes often
-ABD pads are not a primary dressing (should not be next to wound)
-do not use sterile hydrogen peroxide on fresh bleeding wounds
-if albumin <3.5 higher risk for skin breakdowns
-steroids cause inflammation
-nurse does perform the first dressing change
-apply bandage distal to proximal because promotes venous return
-binder is used to immobilize or splint;apply binder when pt is in bed
-heat vasodilates
-cold vasoconstricts
-allow irrigations to flow from superior to inferior edges (with gravity)
isotonic solutions - Answers - 0.9% sodium chloride
-lactated ringers
hydrocolloid dressing - Answers can be cut to size of wound and can last up to a week
nonstick dressings - Answers prevent injury when removing
transparent dressings - Answers -good for IV dressings
-allow visualization
skin barrier creams - Answers protect the skin from drainage, etc.
2% chlohexidine gluconate - Answers -effective preoperative skin antiseptic and surgical scrub, but
toxic to granulation tissue
-start in the middle and work your way out)
Hemovac, Penrose, JP drain - Answers -allow for wound drainage
-must be flat to function
- document amount, color and characteristics of drainage
serous - Answers -pale, yellow and watery
-fluid from blister
sanguineous - Answers bloody, red
serosanguinous - Answers serum and blood, pinkish color
purulent - Answers -green/yellow
-white blood cells
-indicates infection
drainage - Answers color, amount, and odor
pressure dressing - Answers used to control bleeding
delayed wound healing - Answers -as we age we heal slower
-malnutrition (check albumin)
-obesity
-hypoxia (not enough O2 for tissues)
-smoking
-drugs
-diabetics (high sugar vasconstricts, poor circulation and perfusion)
-radiation
-anemia (decreased RBCs)
-cancer
-renal insufficiency
-hypovolemia (clotting doesn't occur quick enough)
-immunocompromised (body can't fight infection)
-surgery longer than 3 hours
-emergency surgery if in poor situation before hand
5 P's of circulation - Answers -pallor
-paresthesia
Hygiene - Answers -remove dentures, glasses and hearing aids from meal tray
-inspect for skin breakdown when bathing
-outside of nurse's scope of practice to trim toe nails
-use electric razor for someone on anticoagulants and soft tooth brush (warfarin)
-line the sink with a towel when cleaning dentures
-turn head to side when performing oral care
- use only warm water for cleaning eyes (no soap)
- effleurage- relaxation massage technique
-diabetic patient don't put lotion between toes
-don't massage reddened areas
-turn patient every 2 hours
mobility - Answers -assistive device goes on strong side of patient
-if coarse crackles in lower lungs, auscultate in high fowlers
-if pt has an aspiration risk keep them in high fowlers
-prolonged bedrest increases the HR
-a pillow under extremities facilitates venous return
-sit pt up when they're on a bedpan
-foot boards can prevent foot drop
-hand boards prevent contractures
-abduction pillow is used for a pt who has had a hip replacement to keep ball in socket
-history of falls is number one indication of falls
-ALWAYS ASSESS PT FIRST
-weak leg and cane move together
-on stairs, stronger leg goes first
-contracture interfere with pt's normal alignment; keep that in mind when moving them
-use logrolling technique if pt has spinal problems or is overweight
four-point crutch walk - Answers can bear weight on all legs
three-point crutch walk - Answers can bear weight on one leg
two-point crutch walk - Answers pt must be able to bear at least partial weight on both legs
swing through crutch walk - Answers pt cannot bear any weight to legs
afferent nervous system - Answers conveys information to the CNS
efferent nervous system - Answers conveys a response from the CNS to the skeletal muscles via the
somatic nervous system
impact on immobility on function - Answers -increase cardiac workload
-decrease lung expansion
-retained secretions
-muscle atrophy
-contractures
-osteoporosis
-anorexia
-negative nitrogen balance
-impaired immunity
-pressure ulcers
-urinary stasis
-UTI
-renal calculi
-constipation
cardiopulmonary prevention - Answers -cough and deep breath
-increase fluids and activity
DVT prevention - Answers TEDs and SCDs
sterile technique - Answers -sterile bottle must be marked with date, time opened, and nurse's
initials
-must discard sterile solution 24-48hours after opening
-moisture contaminates a sterile field
, -sterile field must be above waist, never turn your back on a sterile field, outer 1 inch boarder is not
sterile
-provide pain medication before a dressing change
-cleans gloves to remove it, sterile gloves to change it
-label dressing with date,time, and initial
-wet to dry dressing is mechanical debridement
-Montgomery straps are the things that look like shoe laces and used for large abdominal wounds
that need dressing changes often
-ABD pads are not a primary dressing (should not be next to wound)
-do not use sterile hydrogen peroxide on fresh bleeding wounds
-if albumin <3.5 higher risk for skin breakdowns
-steroids cause inflammation
-nurse does perform the first dressing change
-apply bandage distal to proximal because promotes venous return
-binder is used to immobilize or splint;apply binder when pt is in bed
-heat vasodilates
-cold vasoconstricts
-allow irrigations to flow from superior to inferior edges (with gravity)
isotonic solutions - Answers - 0.9% sodium chloride
-lactated ringers
hydrocolloid dressing - Answers can be cut to size of wound and can last up to a week
nonstick dressings - Answers prevent injury when removing
transparent dressings - Answers -good for IV dressings
-allow visualization
skin barrier creams - Answers protect the skin from drainage, etc.
2% chlohexidine gluconate - Answers -effective preoperative skin antiseptic and surgical scrub, but
toxic to granulation tissue
-start in the middle and work your way out)
Hemovac, Penrose, JP drain - Answers -allow for wound drainage
-must be flat to function
- document amount, color and characteristics of drainage
serous - Answers -pale, yellow and watery
-fluid from blister
sanguineous - Answers bloody, red
serosanguinous - Answers serum and blood, pinkish color
purulent - Answers -green/yellow
-white blood cells
-indicates infection
drainage - Answers color, amount, and odor
pressure dressing - Answers used to control bleeding
delayed wound healing - Answers -as we age we heal slower
-malnutrition (check albumin)
-obesity
-hypoxia (not enough O2 for tissues)
-smoking
-drugs
-diabetics (high sugar vasconstricts, poor circulation and perfusion)
-radiation
-anemia (decreased RBCs)
-cancer
-renal insufficiency
-hypovolemia (clotting doesn't occur quick enough)
-immunocompromised (body can't fight infection)
-surgery longer than 3 hours
-emergency surgery if in poor situation before hand
5 P's of circulation - Answers -pallor
-paresthesia
