NUR 242 Exam 1
The nurse notices a localized red area that is nonblanchable on the the patient's coccyx.
What stage pressure injury is this recognized as? - 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? - 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? - ANSWER--WBC - elevated
-Creatinine- elevated
-Bicarbonate- low
-Albumin- low
-Calcium- low
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? -
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 - 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. - 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? - 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? -
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? - 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
What pain rating scale might you use for a child or a nonverbal patient? - 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 - 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? - 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? - ANSWER-The patient will verbalize feeling
a sensation of pins and needles.
The nurse notices a localized red area that is nonblanchable on the the patient's coccyx.
What stage pressure injury is this recognized as? - 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? - 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? - ANSWER--WBC - elevated
-Creatinine- elevated
-Bicarbonate- low
-Albumin- low
-Calcium- low
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? -
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 - 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. - 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? - 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? -
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? - 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
What pain rating scale might you use for a child or a nonverbal patient? - 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 - 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? - 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? - ANSWER-The patient will verbalize feeling
a sensation of pins and needles.
