NUR 242 Exam 1 Med-Surg Tested (Latest ) GALEN(A+
Guarantee)
Patricia is an RN working at a rehabilitation center and witnesses a nurse
aid struggling to lift and reposition an elderly, bed ridden patient. She
explains to the nurse aide that there is a No Lift Policy in place in the
establishment. What does this policy entail? - ANS>> The concept of a no-
lift policy is a pledge from administrators that proper equipment, adequately
maintained and in sufficient numbers, will be available to care providers to
reduce the risks associated with manual patient handling
How often should the nurse monitor patient's vital signs when they are
receive a blood transfusion? - ANS>> Vital sings must be checked after 15
minutes, 30 minutes, and one hour followed by every hour after.
Immobility effects multiple body systems. What are some interventions that
you can implement to decrease these effects? Select all that apply.
A. Utilizing waffle mattress to reduce the need for repositioning
B. Teds/SCDs
C. Rubbing reddened areas
D. Limiting fluid intake
E. ROM exercises - ANS>> Answer: B and E
Rational:
-A is incorrect because regardless of implemented mattress, positioning
should be every 2 hours
-C is incorrect. You should not rub at reddened areas. This increases the
risk for skin break.
, -D is incorrect. You should encourage proper hydration to promote well
hydrated and healthy skin.
True or False: Nurses should do skin assessments once a week. - ANS>>
False
Rational: Nurses should do full skin assessments a minimum of once per
shift.
A pt goes to the ER for swelling and pain in her right calf. The PT states
that it occurred after she accidentally cut herself. Based on her symptoms,
what skin condition might the nurse suspect the patient has? - ANS>>
Cellulitis.
Cellulitis is inflammation of the skin and subq tissue.
Pt A is admitted from a nursing home with a stage 3 pressure ulcer. When
creating his plan of care, who else would be involved besides the primary
care physician? - ANS>> Wound care nurse, Dietician, Physical therapist.
OT can also be included, however they deal more with fine motor skills.
An 85 year old woman is admitted to the hospital. When doing the initial
assessment, what are some factors that you know put her at risk for
pressure injuries? - ANS>> -if the pt is immobile
-if the pt is incontinent
-if the pt has comorbidities such as diabetes or PVD
-if the pt is malnourished or dehydrated
-if the pt suffers from decreased sensory perception
A pt asks you why what he eats has anything to do with wound healing.
What is your response? - ANS>> Successful healing of pressure injuries
depends on adequate intake of calories protein, vitamins, minerals and
water.
After receiving shift report, the night nurse looks at the lab values for a
patient with cellulitis. What abnormal lab values might you see? - ANS>> -
WBC - elevated
-Creatinine- elevated
-Bicarbonate- low
Guarantee)
Patricia is an RN working at a rehabilitation center and witnesses a nurse
aid struggling to lift and reposition an elderly, bed ridden patient. She
explains to the nurse aide that there is a No Lift Policy in place in the
establishment. What does this policy entail? - ANS>> The concept of a no-
lift policy is a pledge from administrators that proper equipment, adequately
maintained and in sufficient numbers, will be available to care providers to
reduce the risks associated with manual patient handling
How often should the nurse monitor patient's vital signs when they are
receive a blood transfusion? - ANS>> Vital sings must be checked after 15
minutes, 30 minutes, and one hour followed by every hour after.
Immobility effects multiple body systems. What are some interventions that
you can implement to decrease these effects? Select all that apply.
A. Utilizing waffle mattress to reduce the need for repositioning
B. Teds/SCDs
C. Rubbing reddened areas
D. Limiting fluid intake
E. ROM exercises - ANS>> Answer: B and E
Rational:
-A is incorrect because regardless of implemented mattress, positioning
should be every 2 hours
-C is incorrect. You should not rub at reddened areas. This increases the
risk for skin break.
, -D is incorrect. You should encourage proper hydration to promote well
hydrated and healthy skin.
True or False: Nurses should do skin assessments once a week. - ANS>>
False
Rational: Nurses should do full skin assessments a minimum of once per
shift.
A pt goes to the ER for swelling and pain in her right calf. The PT states
that it occurred after she accidentally cut herself. Based on her symptoms,
what skin condition might the nurse suspect the patient has? - ANS>>
Cellulitis.
Cellulitis is inflammation of the skin and subq tissue.
Pt A is admitted from a nursing home with a stage 3 pressure ulcer. When
creating his plan of care, who else would be involved besides the primary
care physician? - ANS>> Wound care nurse, Dietician, Physical therapist.
OT can also be included, however they deal more with fine motor skills.
An 85 year old woman is admitted to the hospital. When doing the initial
assessment, what are some factors that you know put her at risk for
pressure injuries? - ANS>> -if the pt is immobile
-if the pt is incontinent
-if the pt has comorbidities such as diabetes or PVD
-if the pt is malnourished or dehydrated
-if the pt suffers from decreased sensory perception
A pt asks you why what he eats has anything to do with wound healing.
What is your response? - ANS>> Successful healing of pressure injuries
depends on adequate intake of calories protein, vitamins, minerals and
water.
After receiving shift report, the night nurse looks at the lab values for a
patient with cellulitis. What abnormal lab values might you see? - ANS>> -
WBC - elevated
-Creatinine- elevated
-Bicarbonate- low
