1. 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 adminis- trators that proper
equipment, adequately maintained and in sufficient numbers, will be available to care
providers to reduce the risks associated with manual patient handling
2. 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: Answer
mailto:https://www.stuvia.com/user/Wisdoms
, Ans: 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 health
skin.
3. True or False: Nurses should do skin assessments once a week.: False
Rational: Nurses should do full skin assessments a minimum of once per shift.
4. 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.
5. 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.
6. 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
mailto:https://www.stuvia.com/user/Wisdoms
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 adminis- trators that proper
equipment, adequately maintained and in sufficient numbers, will be available to care
providers to reduce the risks associated with manual patient handling
2. 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: Answer
mailto:https://www.stuvia.com/user/Wisdoms
, Ans: 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 health
skin.
3. True or False: Nurses should do skin assessments once a week.: False
Rational: Nurses should do full skin assessments a minimum of once per shift.
4. 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.
5. 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.
6. 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
mailto:https://www.stuvia.com/user/Wisdoms
