NUR 106 FINAL EXAM QUESTIONS WITH VERIFIED
ANSWERS
What is a fall risk? - Answers - Inpatients who have a history of falling, or meet certain
criteria are noted to be at increased risk for a fall and require assistance to move
What is the name of the scale used to determine if someone is a fall risk? - Answers -
The Braden Scale
Why and how are restraints used? - Answers - To keep a person safe from harming
themselves or others. They are temporary used by either physical restraint or
medication. Can only be used with an order from a Doctor.
How do you document the use of restraints? - Answers - The doctor who ordered them,
what type of restraint was used, where the restraint was placed, who placed the
restraint, what time they were placed
What are factors that could go into someone becoming a fall risk? - Answers - lower
body weakness, poor vision, gait or balance issues, issues with the feet and/or shoes,
postural dizziness, hazards in the home and community
What is elder abuse? - Answers - a single, or repeated act, or lack of appropriate action,
occurring within any relationship where there is an expectation of trust, which causes
harm or distress to an older person
What does an incentive spirometer do? - Answers - give pts *immediate visual
feedback* about their maximal inspiratory effort, assists the patient to breathe slowly
and deeply to sustain maximal inspiration
What is suctioning used for? - Answers - To clear sputum
What should you do prior/during suctioning? - Answers - Hyper-oxygenate prior to
suctioning, place the patient into semi-fowlers, the suction gage set to 120-150,
suctioning only 10-15 seconds at a time, with 30 seconds-1 minute between suctions
What is a trach used for? - Answers - provides an air passage to help you breathe when
the usual route for breathing is blocked or reduced.
What is the most accurate oxygen delivery device used to know how much oxygen a
person is receiving? The least accurate? - Answers - Most: Venturi Mask Least: Nasal
Cannula
, Name the common types of diets - Answers - Regular, Clear Liquid, Full Liquid, Pureed,
Mechanical or dental soft, Soft, High Fiber, Sodium Restricted, Low Cholesterol
Describe a nasogastric tube - Answers - used for short term nutritional support
How can you be sure that a NG tube is in the correct place? - Answers - Radiographic
exam, measurement of pH and visual assessment of aspirate, measure the tube length
and tube marking, carob dioxide monitoring
Process in which a NG tube is used - Answers - Raise the bed to a comfortable
position, check placement of the tube every 4-6 hours, flush tubes with 30mL of water
every 4 hours, Raise to high-fowlers when feeding, have patient remain upright for 1
hour after eating to prevent aspiration, 1-2 oz of fluid inside the feeding bag for irrigation
Similarities in urinary catheterization with male and female - Answers - Sterile
procedure, relieve urinary retention (no more than 1000mL from bladder at a time to
prevent spasms), remove residual urine, empty bladder before surgery
Differences in urinary catheterizations with male and female - Answers - Male have
longer urethra, prostate enlargement, may need to retract foreskin. With male,
lubrication is placed inside the urethra, with women lubrication is placed on the catheter
itself
What type of catheter is used for a sterile urine specimen? - Answers - Straight or
intermittent
What are the amounts that determine if a bladder is distended - Answers - >50
demonstrates accurate emptying, <100 means the bladder is not emptying properly
What is a bladder scan used for? - Answers - a easy and noninvasive way to determine
how full ones bladder is. The patient must void right before the scan and needs to be in
supine position
What do absent bowel sounds indicate? - Answers - bowel strangulation or a
mechanically obstructed bowel, peritonitis makes the abdomen inflamed and can cause
bowel blockage
What do increased bowel sounds indicate? - Answers - Diarrhea or early bowel
obstruction
What do decreased bowel sounds indicate? - Answers - Late bowel obstruction, or after
abdominal surgery
What is the order in how you should assess the bowel - Answers - Inspection,
auscultation, percussion, palpate
ANSWERS
What is a fall risk? - Answers - Inpatients who have a history of falling, or meet certain
criteria are noted to be at increased risk for a fall and require assistance to move
What is the name of the scale used to determine if someone is a fall risk? - Answers -
The Braden Scale
Why and how are restraints used? - Answers - To keep a person safe from harming
themselves or others. They are temporary used by either physical restraint or
medication. Can only be used with an order from a Doctor.
How do you document the use of restraints? - Answers - The doctor who ordered them,
what type of restraint was used, where the restraint was placed, who placed the
restraint, what time they were placed
What are factors that could go into someone becoming a fall risk? - Answers - lower
body weakness, poor vision, gait or balance issues, issues with the feet and/or shoes,
postural dizziness, hazards in the home and community
What is elder abuse? - Answers - a single, or repeated act, or lack of appropriate action,
occurring within any relationship where there is an expectation of trust, which causes
harm or distress to an older person
What does an incentive spirometer do? - Answers - give pts *immediate visual
feedback* about their maximal inspiratory effort, assists the patient to breathe slowly
and deeply to sustain maximal inspiration
What is suctioning used for? - Answers - To clear sputum
What should you do prior/during suctioning? - Answers - Hyper-oxygenate prior to
suctioning, place the patient into semi-fowlers, the suction gage set to 120-150,
suctioning only 10-15 seconds at a time, with 30 seconds-1 minute between suctions
What is a trach used for? - Answers - provides an air passage to help you breathe when
the usual route for breathing is blocked or reduced.
What is the most accurate oxygen delivery device used to know how much oxygen a
person is receiving? The least accurate? - Answers - Most: Venturi Mask Least: Nasal
Cannula
, Name the common types of diets - Answers - Regular, Clear Liquid, Full Liquid, Pureed,
Mechanical or dental soft, Soft, High Fiber, Sodium Restricted, Low Cholesterol
Describe a nasogastric tube - Answers - used for short term nutritional support
How can you be sure that a NG tube is in the correct place? - Answers - Radiographic
exam, measurement of pH and visual assessment of aspirate, measure the tube length
and tube marking, carob dioxide monitoring
Process in which a NG tube is used - Answers - Raise the bed to a comfortable
position, check placement of the tube every 4-6 hours, flush tubes with 30mL of water
every 4 hours, Raise to high-fowlers when feeding, have patient remain upright for 1
hour after eating to prevent aspiration, 1-2 oz of fluid inside the feeding bag for irrigation
Similarities in urinary catheterization with male and female - Answers - Sterile
procedure, relieve urinary retention (no more than 1000mL from bladder at a time to
prevent spasms), remove residual urine, empty bladder before surgery
Differences in urinary catheterizations with male and female - Answers - Male have
longer urethra, prostate enlargement, may need to retract foreskin. With male,
lubrication is placed inside the urethra, with women lubrication is placed on the catheter
itself
What type of catheter is used for a sterile urine specimen? - Answers - Straight or
intermittent
What are the amounts that determine if a bladder is distended - Answers - >50
demonstrates accurate emptying, <100 means the bladder is not emptying properly
What is a bladder scan used for? - Answers - a easy and noninvasive way to determine
how full ones bladder is. The patient must void right before the scan and needs to be in
supine position
What do absent bowel sounds indicate? - Answers - bowel strangulation or a
mechanically obstructed bowel, peritonitis makes the abdomen inflamed and can cause
bowel blockage
What do increased bowel sounds indicate? - Answers - Diarrhea or early bowel
obstruction
What do decreased bowel sounds indicate? - Answers - Late bowel obstruction, or after
abdominal surgery
What is the order in how you should assess the bowel - Answers - Inspection,
auscultation, percussion, palpate
