PCA Exam Test Study Guide Questions and Answers

PCA Exam Test Study Guide Questions and Answers What are some risk factors of skin breakdown? Limited physical ability, age, lack of hydration, poor nutrition, etc. What is the name of the assessment scale used to help determine if a patient is at a greater risk of developing pressure ulcers? Braden Scale _________ is a localized injury to the skin and/or the underlying tissue. It is a result of presence over a bony prominence. Pressure injury What is the main governing body that determines what a PCA does? State Nursing Practice Act What are the 5 rights of delegation? Right task Right person Right direction of communication Right circumstance Right supervision ____________ is defined as being responsible for one's own actions of others who perform delegated tasks. Accountability _____________ is defined as the duty or obligation to perform some act or function. Responsibility ______________ is defined as the skills, care and judgement required by the health care team member under similar conditions. Standard of care What stage of pressure ulcer is this? Reddened area not returning to normal color after pressure is relieved. Feels hot and/or painful. Skin is intact. Stage 1 __________ is defined as unlawful restraint or restriction of a person's freedom of movement. False Imprisonment ___________ is defined as the intentional mistreatement or harm of another person. Abuse ___________ is defined as negligence by a professional person. Malpractice ____________ is defined as an intentional wrong in which a person fails to act in a responsible and Negligence What stage of pressure ulcer is this? Skin has broken down Stage 2 What stage of pressure ulcer is this? Skin is broken down to the subcutaneous fatty layer Stage 3 What stage of pressure ulcer is this? Skin is broken down to the muscle and bone. Stage 4 ____________ is a communicable/contagious disease is caused by pathogens that spread easily. Infection What is the best way to prevent infection? Wash hands with soap and water If a patient has C.diff what is the best way to wash your hands? Soap and water ___________ is an infection acquired during a stay at a health care facility. Noscomial Infection What are ways we can prevent skin breakdown? Support surfaces Initiate turning Proper nutrition Encourage ambulation Lift rather than slide Shift weight every so often Elevate heel Get rid of wrinkles in bed linens Provide skin care What are the 4 P's to check during hourly rounding? Pain, Potty, Possessions, Position T/F: A patient can be burned from hot and cold applications. True A heat application _____________ vessels. dilates A cold application __________________ vessels. Constricts T/F: Vital signs provide essential information about a person's health? True T/F: A change in a person's vital sign measurements can be a sign of illness. True T/F: You should take vital signs only once even if the measurements are abnormal. False - You should take vital signs no matter what unless the nurse or physician tells you not to. T/F: If you are having difficulty measuring a patient's vital signs, you should ask for help from the nurse. True T/F: A patient's vital signs will be the same throughout the day. False - they will always change T/F: It does not make any difference how you take a temperature, the results will be the same. False - the several ways to take a temperature will give different results depending on where on the body the temperature is taken T/F: It is important to use the correct blood pressure cuff size when measuring a person's blood pressure. True - if a cuff is too big or too small, you will get a false high or a false low result T/F: When measuring a patient's respirations, one breath is the inspiration and the expiration cycle. True T/F: A radial pulse is palpated by using the thumb over the radial pulse. False - you use your index and middle finger T/F: It is not important to note on documentation or when reporting to the nurse how you took the patient's temperature. False - it is important to note and document when reporting to the nurse T/F: A pulse oximeter measured oxygen saturation and respirations. False - it measures the oxygen saturation and heart rate What are six factors that could have an effect on a person's vital signs? infection anxiety pain cold injury medications exercise medical conditions Know the normal ranges for vital signs. Know the normal ranges for vital signs. You report vital sign managements immediately to the nurse if they are abnoramally ____________ or _________. high or low Besides the rate when taking a pulse, what do you need to be aware of? regularity and strength of pulse _________ means decreased heart rate. Bradycardia _____________ means increased heart rate. Tachycardia ________ means decreased BP. Hypotension ____________ means increased BP. Hypertension ____________ means blood pressure decreases when the person changes positions too quickly. Orthostatic hypotension A _____________ infection means it can be spread from one person to another. a) communicable b) infectious c) noscomial d) systemic a) Communicable