NUR 311 Final Exam Study Guide
•Full-thickness tissue loss. Subcutaneous fat may
be visible, but bone, tendon, or muscle are not
exposed Correct Answers Stage III
A nurse is assisting a patient to ambulate when the
patient begins to fall. What should you do? Correct
Answers Place feet wide apart with one foot in
front
A patient reports numbness in the extremity after a
figure-eight bandage is applied. What is the nurse's
best course of action? Correct Answers take it off
and wait 30 minutes. Reapply with less tension
Accuracy of readings obtained from pulse oximetry
can be influenced by conditions that decrease
arterial blood flow, such as? Correct Answers
Peripheral vascular disease and hypertension
Are all hot compresses made to the same
temperature? If no, who has special
considerations? Correct Answers No;
Elderly, young children, diabetics, and people who
are unconscious.
At what point do you know a wound has been
adequately irrigated? Correct Answers When the
saline is clear coming out of the wound.
,Can patients with a leg incision wear compression
stockings? If so, what is the correct process?
Correct Answers Yes. Avoid hitting incision directly
and have a bandage over the incision.
Describe the main difference in a J-P drain and
Hemovac collection devices? Correct Answers JP-
uses a bulb
Hemovac- spring loaded
Do you use the same swab for each naris?
Why/why not? Correct Answers Yes. It gets a more
accurate specimen.
Explain the process for cleaning the drain site.
Correct Answers Start at the drain tube, use a
circular motion and move away from the drain site.
For a sputum specimen, why should the patient be
cautioned to avoid spitting saliva secretion into the
sterile container? Correct Answers
For those patients who are immobile and cannot
use compression stockings, what can be used to
prevent venous stasis? Correct Answers
pneumatic compression devices
For what patient care would the nurse use surgical
asepsis?
, A. Administering medications
B. Inserting an IV catheter
C. Providing a bed bath
D. Changing the linens on a bed Correct Answers
B. Inserting an IV catheter
Full-thickness tissue loss with exposed bone,
tendon, or muscle Correct Answers Stage IIII
How can you decrease a patient's gag reflex when
obtaining a nasopharyngeal swab? Correct
Answers Use a tongue depressor slightly off
center. This bypasses the gag reflex.
How do you check the gag reflex in an
unresponsive client? Correct Answers stick tool in
mid to back tongue and check for reflex. No reflex
could lead to aspiration
How do you clean a wound? Correct Answers top
to bottom; center to outside (use new glaze for
each wipe
How do you clean dentures? Correct Answers
How do you clean the oral cavity of a client who
wears dentures? Correct Answers •Use a soft
bristle toothbrush and paste to gently clean gums,
mucous membranes, and tongue.
•Full-thickness tissue loss. Subcutaneous fat may
be visible, but bone, tendon, or muscle are not
exposed Correct Answers Stage III
A nurse is assisting a patient to ambulate when the
patient begins to fall. What should you do? Correct
Answers Place feet wide apart with one foot in
front
A patient reports numbness in the extremity after a
figure-eight bandage is applied. What is the nurse's
best course of action? Correct Answers take it off
and wait 30 minutes. Reapply with less tension
Accuracy of readings obtained from pulse oximetry
can be influenced by conditions that decrease
arterial blood flow, such as? Correct Answers
Peripheral vascular disease and hypertension
Are all hot compresses made to the same
temperature? If no, who has special
considerations? Correct Answers No;
Elderly, young children, diabetics, and people who
are unconscious.
At what point do you know a wound has been
adequately irrigated? Correct Answers When the
saline is clear coming out of the wound.
,Can patients with a leg incision wear compression
stockings? If so, what is the correct process?
Correct Answers Yes. Avoid hitting incision directly
and have a bandage over the incision.
Describe the main difference in a J-P drain and
Hemovac collection devices? Correct Answers JP-
uses a bulb
Hemovac- spring loaded
Do you use the same swab for each naris?
Why/why not? Correct Answers Yes. It gets a more
accurate specimen.
Explain the process for cleaning the drain site.
Correct Answers Start at the drain tube, use a
circular motion and move away from the drain site.
For a sputum specimen, why should the patient be
cautioned to avoid spitting saliva secretion into the
sterile container? Correct Answers
For those patients who are immobile and cannot
use compression stockings, what can be used to
prevent venous stasis? Correct Answers
pneumatic compression devices
For what patient care would the nurse use surgical
asepsis?
, A. Administering medications
B. Inserting an IV catheter
C. Providing a bed bath
D. Changing the linens on a bed Correct Answers
B. Inserting an IV catheter
Full-thickness tissue loss with exposed bone,
tendon, or muscle Correct Answers Stage IIII
How can you decrease a patient's gag reflex when
obtaining a nasopharyngeal swab? Correct
Answers Use a tongue depressor slightly off
center. This bypasses the gag reflex.
How do you check the gag reflex in an
unresponsive client? Correct Answers stick tool in
mid to back tongue and check for reflex. No reflex
could lead to aspiration
How do you clean a wound? Correct Answers top
to bottom; center to outside (use new glaze for
each wipe
How do you clean dentures? Correct Answers
How do you clean the oral cavity of a client who
wears dentures? Correct Answers •Use a soft
bristle toothbrush and paste to gently clean gums,
mucous membranes, and tongue.
