APEA Predictor Practice Questions

A. Utilizing waffle mattress to reduce the need for repositioning B. Teds/SCDs C. Rubbing reddened areas D. Limiting fluid intake 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? - ANSWERSThe 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. E. ROM exercises - ANSWERSAnswer: 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. - ANSWERSFalse 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? - ANSWERSCellulitis. 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? - ANSWERSWound 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? - ANSWERS-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? - ANSWERSStage 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? - ANSWERSSuccessful 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? - ANSWERS-WBC - elevated -Creatinine- elevated -Bicarbonate- low -Albumin- low -Calcium- low What pain rating scale might you use for a child or a nonverbal patient? - ANSWERSWong 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 - ANSWERSC. 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? - ANSWERSinstraspinal 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? - ANSWERSThe 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? - ANSWERSMorphine 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? - ANSWERSConstipation. 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? - ANSWERSConstructive A biopsy is what type of procedure? - ANSWERSDiagnostic This type of surgery prolongs life but does not cure the underlying disease - ANSWERSPalliative A patient has received 10 mg of Morphine via IV 20 minutes ago and is noticeably groggy. The physician requests you witness the signature of his informed consent. How would you, as a patient advocate, proceed? - ANSWERSInformed consent should be received before patient is given any preop analgesics to ensure a clear state of mind. Side note: A nurse is not responsible for clarification of risks or procedure explanation. A nurse can witness signature. Pneumonia and Atelectasis are serious concerns post op. What are some things that we can encourage the patient to do to prevent these complications? - ANSWERSIncentive spirometry, coughing, and deep breathing After surgery, Pt A verbalizes they do not want to cough because it is uncomfortable. What are some things the nurse can do to minimize discomfort? - ANSWERSAnalgesic administration and educating on splinting incision site when coughing. Why is it important for a pt to ambulate and wear SCDs or TED stockings after a procedure? - ANSWERSTo reduce the risk of DVT A pt's health history states that they are on corticosteroids. The PACU nurse that this increases the risk of what? - ANSWERSwound dehiscence After a procedure, what should the nurse assess immediately? - ANSWERSABC's Make sure airway is clear, note respiration depth, listen to lung sounds After a procedure, a pt's vitals signs are the following: BP: 90/50 RR: 26 HR: 110 O2: 88% What is this a potential sign of?