NUR 242 Final Exam Review QUESTIONS AND ANSWERS

Exam 1: Correct Answer: Cane: Correct Answer: -Appropriate height (at wrist level when arm is at side) -Pt strong hand on cane *MOVE CANE WITH WEAKER LEG* At risk for falls due to: Correct Answer: incontenience Transferring pt to WC: Correct Answer: -Place WC on strong side angled to bed -Strong hand to armrest, then pivot Safe pt handling: Correct Answer: -Keep pt directly in front of you and as close as possible to prevent back injuries Skin integrity: Correct Answer: -dont wear restrictive clothing -WC pt lift themselves off buttock for 10 seconds q1hr Pressure Ulcer stages: Correct Answer: *Stage 2- skin is not intact; open or fluid blister* Wet-to-damp wound care: Correct Answer: mechanically removes necrotic tissue does more damage than good bc it removes the good tissue as well Informed consent: Correct Answer: -surgeon is responsible for having consent signed -Pt who can not sign can sign with an "X" but must be witnessed by two people -If the pt doesn't understand the surgery, the surgeon has to be notified -A blind pt can sign the consent, has to be witnessed by 2 people -Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt Pre-OP: Correct Answer: -Report these to surgeon: -increased PT/INR/aPTT/Creatinine -Verify operative permit is signed -Side rails up, bed down, call light within reach Intra-OP: Correct Answer: -Pts are lifted into position onto the OR table to prevent shearing -Gel pads are placed on the OR table to prevent pressure ulcers -Warming blankets are used -Cover the pts head and feet (decrease hypothermia) *If saving is necessary, hair should be removed using disposable sterile supplies immediately before the start of the procedure* -Sterile scrubbing from fingertips to elbow for 3-5 minutes