NURS 242 EXAM 1 ACTUAL UPDATED
Exam Questions and CORRECT Answers
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
Exam Questions and CORRECT Answers
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
