Pnu 120 Exam 3 final questions with
correct answers
Caring for an incontinent patient - ** VERIFIED ANSWERS **✔✔Keep skin clean
• Do not scrub bony prominences
• Reposition every 2 hrs
• Adequate hydration
• Clean skin with mild soap
Aspiration Signs/Symptoms - ** VERIFIED ANSWERS **✔✔-coughing
Watery eyes
• Difficulty swallowing
• Shortness of breath
-raspy breathing
-pain in chest
-nausea
-distress, anxiety
•
Nursing interventions to promote sleep. - ** VERIFIED ANSWERS **✔✔Prepare a restful
environment.
Promote bedtime rituals.
Promote relaxation and comfort.
Teach about rest and sleep.
Respect normal sleep-wake patterns.
Schedule nursing care to avoid disturbances.
,Use medications to produce sleep.
Offer appropriate bedtime snacks and beverages.
Dysphagia diet - ** VERIFIED ANSWERS **✔✔- pureed food and thickened liquids
- also tucking the chin when swallowing helps propel food down the esophagus more easily
-soft diet
See speech therapist
dysphagia - ** VERIFIED ANSWERS **✔✔difficulty swallowing
speech therapist - ** VERIFIED ANSWERS **✔✔treats and prevents speech and language disorders
like dysphagia
Ileostomy Care - ** VERIFIED ANSWERS **✔✔apply skin barriers to stoma,
empty bag when it is 1/3 full,
assess for fluid and electrolyte imbalances
Output will be loose and watery
• Stoma should be pink or red and moist
• If leaking, whole appliance needs to be changed
Phlebitis/thrombophlebitis prevention - ** VERIFIED ANSWERS **✔✔Prevention: rotate sites every
72-96 hrs; secure catheter; use aseptic technique; for PICCs, avoid excessive activity with the
extremity.
phlebitis treatment - ** VERIFIED ANSWERS **✔✔1) remove peripheral catheter at first sign of
phlebitis, use warm compresses to relieve pain;
Elevated the extremity
2) monitor frequently,
3) document using phlebitis scale;
4) insert new cath using opposite extremity;
, 5) mechanical phlebitis occurring in 1st week after PICC insertion may be treated w/o cath removal;
apply continuous heat, rest and elevate extremity; significant improvement is seen in 24 hr and
complete resolution is seen w/in 72 hr; remove cath if treatment is unsuccessful
Phlebitis is - ** VERIFIED ANSWERS **✔✔Inflammation of the vein
• A catheter could be rubbing against the vein
• pH or osmolality of the medication that's being infused
Phlebitis s/s - ** VERIFIED ANSWERS **✔✔erythema, pain, warmth, hard vein, red streak
Infiltration - ** VERIFIED ANSWERS **✔✔• IV fluids or medications leak into the surrounding
tissue
infiltration signs and symptoms - ** VERIFIED ANSWERS **✔✔Swelling, pallor, coldness,
dampness or pain around the infusion site; significant decrease in the flow rate
fluid may be leaking from the IV site itself
infiltration interventions - ** VERIFIED ANSWERS **✔✔-->Stop the Infusion and Remove Catheter
-->Elevate the Extremity
• apply warm or cold compress
Wrist Restraints - ** VERIFIED ANSWERS **✔✔• A doctor's order is required
• 2 fingers should fit easily
• Use a quick-release tie
• Secure it to bed frame
• Re-assess and remove restraints every 2hrs
fluid volume deficit/hypovolemia - ** VERIFIED ANSWERS **✔✔• Risk factors: excess vomiting,
diuretics, hemorrhaging, hyperventilation
correct answers
Caring for an incontinent patient - ** VERIFIED ANSWERS **✔✔Keep skin clean
• Do not scrub bony prominences
• Reposition every 2 hrs
• Adequate hydration
• Clean skin with mild soap
Aspiration Signs/Symptoms - ** VERIFIED ANSWERS **✔✔-coughing
Watery eyes
• Difficulty swallowing
• Shortness of breath
-raspy breathing
-pain in chest
-nausea
-distress, anxiety
•
Nursing interventions to promote sleep. - ** VERIFIED ANSWERS **✔✔Prepare a restful
environment.
Promote bedtime rituals.
Promote relaxation and comfort.
Teach about rest and sleep.
Respect normal sleep-wake patterns.
Schedule nursing care to avoid disturbances.
,Use medications to produce sleep.
Offer appropriate bedtime snacks and beverages.
Dysphagia diet - ** VERIFIED ANSWERS **✔✔- pureed food and thickened liquids
- also tucking the chin when swallowing helps propel food down the esophagus more easily
-soft diet
See speech therapist
dysphagia - ** VERIFIED ANSWERS **✔✔difficulty swallowing
speech therapist - ** VERIFIED ANSWERS **✔✔treats and prevents speech and language disorders
like dysphagia
Ileostomy Care - ** VERIFIED ANSWERS **✔✔apply skin barriers to stoma,
empty bag when it is 1/3 full,
assess for fluid and electrolyte imbalances
Output will be loose and watery
• Stoma should be pink or red and moist
• If leaking, whole appliance needs to be changed
Phlebitis/thrombophlebitis prevention - ** VERIFIED ANSWERS **✔✔Prevention: rotate sites every
72-96 hrs; secure catheter; use aseptic technique; for PICCs, avoid excessive activity with the
extremity.
phlebitis treatment - ** VERIFIED ANSWERS **✔✔1) remove peripheral catheter at first sign of
phlebitis, use warm compresses to relieve pain;
Elevated the extremity
2) monitor frequently,
3) document using phlebitis scale;
4) insert new cath using opposite extremity;
, 5) mechanical phlebitis occurring in 1st week after PICC insertion may be treated w/o cath removal;
apply continuous heat, rest and elevate extremity; significant improvement is seen in 24 hr and
complete resolution is seen w/in 72 hr; remove cath if treatment is unsuccessful
Phlebitis is - ** VERIFIED ANSWERS **✔✔Inflammation of the vein
• A catheter could be rubbing against the vein
• pH or osmolality of the medication that's being infused
Phlebitis s/s - ** VERIFIED ANSWERS **✔✔erythema, pain, warmth, hard vein, red streak
Infiltration - ** VERIFIED ANSWERS **✔✔• IV fluids or medications leak into the surrounding
tissue
infiltration signs and symptoms - ** VERIFIED ANSWERS **✔✔Swelling, pallor, coldness,
dampness or pain around the infusion site; significant decrease in the flow rate
fluid may be leaking from the IV site itself
infiltration interventions - ** VERIFIED ANSWERS **✔✔-->Stop the Infusion and Remove Catheter
-->Elevate the Extremity
• apply warm or cold compress
Wrist Restraints - ** VERIFIED ANSWERS **✔✔• A doctor's order is required
• 2 fingers should fit easily
• Use a quick-release tie
• Secure it to bed frame
• Re-assess and remove restraints every 2hrs
fluid volume deficit/hypovolemia - ** VERIFIED ANSWERS **✔✔• Risk factors: excess vomiting,
diuretics, hemorrhaging, hyperventilation
