(NU 311) Exam 1 Questions With Complete Solutions
Accountability Correct Answers Cannot be delegated
ANA Scope and Standards of Practice Correct Answers NOT
laws, but influence policy development
Be familiar with Continuous Passive Motion (CPM) Machine
Correct Answers pg 304-305
Be familiar with elastic stockings and Sequential Compression
Devices (SCD): rationale for use, application, assessment and
care, and safety measure related to use. Correct Answers pg
305-308
Be familiar with The Joint Commision (TJC) Patients' Rights
Standard. Correct Answers pg 15, box 2.3
C = comparison with the intervention Correct Answers Does a
comparison intervention exist? Which standard of care or
current intervention do you usually now use in practice?
Core measures Correct Answers national standards of care and
treatment processes for common conditions; proven to reduce
complications and lead to better patient outcomes
Dorsal recumbent Correct Answers lying on back, knees bent
Explain how to use a fire extinguisher Correct Answers P =
pull pin
A = aim
,S = squeeze handle
S = sweep
Explain restraint application and quick release tie Correct
Answers - Use least restrictive restraint
- Attach restraint straps to a part of the bed frame that moves
with the patient; NEVER the side rail
- Secure restraints on bed frame with quick release tie/buckle;
NEVER a knot
- Ensure restraint is not too tight
- Assess for circulation, sensation, color of restrained body part
- Assess every 15 min for signs of injury
- Released restraints at least every 2 hrs and assess needs for
toileting, food, fluids, mobility
Explain the restraint free goal Correct Answers Serious, often
fatal complications can result from restraints; restraint free is the
goal for all patients; restraints can be chemical or physical
Fall precautions Correct Answers pg 342 and table 14.1
Familiarize yourself with the USA College of Nursing Dress
Code. Correct Answers refer to uniform policy
Fowler's Correct Answers HOB inclined at 45 degrees
High Fowler's Correct Answers HOB inclined at 60-90
degrees
, How do you provide oral hygiene to an unconscious patient?
Correct Answers - Sims position (lying on left side with knee
up), head of bed elevated to at least 30 degrees
How do you provide perineal care to female patients? Correct
Answers Place in dorsal recumbent position (laying on back
with knees up), wipe front to back (perineum to rectum), use
different sections of wash cloth for each front to back stroke
How do you provide perineal care to male patients? Correct
Answers Place in supine position, if patient has erection stop
and come back
How do you provide ROM exercises to patients? Correct
Answers Incorporate active ROM in patient's ALDs;
incorporate passive ROM in bathing/feeding; put patient in
comfortable position, sitting or lying down
- support joint by holding distal and proximal areas adjacent to
joint
- support joint by cradling distal part of extremity
- use cupped hand to support joint
How do you reduce orthostatic hypotension associated injury?
Correct Answers - Allow patient to sit on side of bed for a
minute
- Dangle legs, move back and forth
- Allow legs to touch floor
- If dizziness persists for more than 60 seconds, lay patient down
Accountability Correct Answers Cannot be delegated
ANA Scope and Standards of Practice Correct Answers NOT
laws, but influence policy development
Be familiar with Continuous Passive Motion (CPM) Machine
Correct Answers pg 304-305
Be familiar with elastic stockings and Sequential Compression
Devices (SCD): rationale for use, application, assessment and
care, and safety measure related to use. Correct Answers pg
305-308
Be familiar with The Joint Commision (TJC) Patients' Rights
Standard. Correct Answers pg 15, box 2.3
C = comparison with the intervention Correct Answers Does a
comparison intervention exist? Which standard of care or
current intervention do you usually now use in practice?
Core measures Correct Answers national standards of care and
treatment processes for common conditions; proven to reduce
complications and lead to better patient outcomes
Dorsal recumbent Correct Answers lying on back, knees bent
Explain how to use a fire extinguisher Correct Answers P =
pull pin
A = aim
,S = squeeze handle
S = sweep
Explain restraint application and quick release tie Correct
Answers - Use least restrictive restraint
- Attach restraint straps to a part of the bed frame that moves
with the patient; NEVER the side rail
- Secure restraints on bed frame with quick release tie/buckle;
NEVER a knot
- Ensure restraint is not too tight
- Assess for circulation, sensation, color of restrained body part
- Assess every 15 min for signs of injury
- Released restraints at least every 2 hrs and assess needs for
toileting, food, fluids, mobility
Explain the restraint free goal Correct Answers Serious, often
fatal complications can result from restraints; restraint free is the
goal for all patients; restraints can be chemical or physical
Fall precautions Correct Answers pg 342 and table 14.1
Familiarize yourself with the USA College of Nursing Dress
Code. Correct Answers refer to uniform policy
Fowler's Correct Answers HOB inclined at 45 degrees
High Fowler's Correct Answers HOB inclined at 60-90
degrees
, How do you provide oral hygiene to an unconscious patient?
Correct Answers - Sims position (lying on left side with knee
up), head of bed elevated to at least 30 degrees
How do you provide perineal care to female patients? Correct
Answers Place in dorsal recumbent position (laying on back
with knees up), wipe front to back (perineum to rectum), use
different sections of wash cloth for each front to back stroke
How do you provide perineal care to male patients? Correct
Answers Place in supine position, if patient has erection stop
and come back
How do you provide ROM exercises to patients? Correct
Answers Incorporate active ROM in patient's ALDs;
incorporate passive ROM in bathing/feeding; put patient in
comfortable position, sitting or lying down
- support joint by holding distal and proximal areas adjacent to
joint
- support joint by cradling distal part of extremity
- use cupped hand to support joint
How do you reduce orthostatic hypotension associated injury?
Correct Answers - Allow patient to sit on side of bed for a
minute
- Dangle legs, move back and forth
- Allow legs to touch floor
- If dizziness persists for more than 60 seconds, lay patient down
