) Questions with Revised Rationalized
Answers, (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? - Correct Answer ✔✔ - 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
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 - Correct Answer ✔✔ - 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. - Correct Answer ✔✔ - 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? - Correct Answer ✔✔ - 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? - Correct Answer ✔✔ - 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? - Correct Answer ✔✔ - -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
The nurse notices a localized red area that is nonblanchable on the the patient's coccyx. What stage
pressure injury is this recognized as? - Correct Answer ✔✔ - Stage 1
Stage 1 pressure injury means the skin is intact with a localized area of nonblanchable erythema (fancy
word for redness).
A pt asks you why what he eats has anything to do with wound healing. What is your response? - Correct
Answer ✔✔ - 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? - Correct Answer ✔✔ - -WBC - elevated
, -Creatinine- elevated
-Bicarbonate- low
-Albumin- low
-Calcium- low
What pain rating scale might you use for a child or a nonverbal patient? - Correct Answer ✔✔ - Wong
Baker-Faces Scale
When assessing a pt's pain. He tells you that the pain comes and goes. What part of the pain assessment
is he describing?
A. Quality
B. Intensity
C. Onset and Duration
D. Location - Correct Answer ✔✔ - C. Onset and Duration
When explaining to a pt what an intraspinal analgesic the pt states "So the medication will be given to
me through the IV in my arm." How would you correct him? - Correct Answer ✔✔ - instraspinal
analgesics are delivered into the epidural space of the spine, also known as the subarachnoid space.
When adjusting a TENs machine on a patient, how do you know the conduction of electricity has
reached a therapeutic level? - Correct Answer ✔✔ - The patient will verbalize feeling a sensation of
pins and needles.
Your pt verbalizes a pain of 2/10 and requests their dose of morphine. How would you educate your pt?
- Correct Answer ✔✔ - Morphine is an opioid analgesic used for moderate to severe pain.
What is the most common side effect of analgesic use and how can we prevent it? - Correct Answer ✔
✔ - Constipation.
A high fiber diet, plenty of fluids, and stool softeners are prophylactic measures.
The patient is undergoing surgery to fix a cleft palate. What type of surgery is this considered? - Correct
Answer ✔✔ - Constructive
A biopsy is what type of procedure? - Correct Answer ✔✔ - Diagnostic