NUR 106 UPDATED EXAM SCRIPT QUESTIONS AND
SOLUTIONS GRADED A+
✔✔Airborne precautions PPE - ✔✔negative air flow room (airborne infection isolation
room)
N95 respirator
Gown
Gloves
Hand washing
✔✔contact precautions are used when? - ✔✔measures taken to prevent the spread of
diseases transmitted by the physical transfer of pathogens to a susceptible host's body
surface
✔✔Donning PPE - ✔✔Hand Hygiene!
1. gown
2. mask
3. goggles
4. gloves
" From Bottom UP (hands in the air)"
✔✔Doffing PPE - ✔✔1. Gloves
2. Gown
3. Goggles
4. Mask
Remove the most soiled to the least soiled
✔✔Proper body mechanics when lifting and moving a patient include
A. maintaining a slight curvature of your back
B. using the muscles of your lower back to lift
C. keeping the weight as close to you as possible
D. twisting at the waist when moving a patient around a corner - ✔✔C. Keeping the
weight as close to you as possible
✔✔Proper body mechanics - ✔✔Keep back straight, bend at knees, keep wide stance,
and keep objects close to body.
Use your knees not your back
No twisting
Raise the bed to safe working height
✔✔Bed Making Procedure while patient is in bed - ✔✔
✔✔Bed Making Procedure - ✔✔1. Carefully unfold sheet on bed
2. Tuck in all four corners of first sheet as hospital corners ensuring no wrinkles
,3. Apply second sheet ensuring only the corner is tucked, not the sides (mitered corner)
4. Apply blanket in the same manner
5. Fold top down
6. Pillow
✔✔What position must the bed be in before leaving the room? - ✔✔Low and locked.
✔✔Patient Positioning - ✔✔Supine: face up
Prone: the person lies on the abdomen with the head turned to the side
Low Fowlers or Semi-Fowlers: 30 degree angle
Fowler's: 45-60 degree angle
High Fowlers: 90 degree angle
Sims
Trendelenburg
Reverse Trendelenburg
Lithotomy
Lateral
✔✔When do we use high Fowler's position? - ✔✔Patient is eating or NG tube insertion
✔✔Effects of Immobility - ✔✔MUSCOSKELETAL:
Disuse osteoporosis: without weight bearing the bone demineralize and become spongy
Disuse atrophy: decrease in size looses normal function
Contractures: permanent shortening of the muscle
Stiffness and pain in the joints- ankylosis
CARDIOVASCULAR:
Diminished cardiac reserve
Increased use of Vasalva maneuver
Orthostatic (postural) hypo tension
Venous vasodilation and stasis
Dependent edema
Thrombus formation
Thrombophlebitis (impaired venous return, hypercoagulability, injury to a blood vessel)
Thrombus (clot)
Embolus
RESPIRATORY:
Decreased respiratory movement
Shallow respirations and decreased vital capacity
Pooling of secretions
Hypostatic pneumonia
Atelectasis
METABOLIC:
Decreased metabolic rate
Basal metabolic rate
Negative nitrogen balance
Anabolism/catabolism
,Anorexia
Negative calcium balance
URINARY:
Urinary stasis: lack of gravity
Renal calculi: Increase calcium salt
Urine become alkaline
Urinary retention accumulation of urine
Urinary incontinence: involuntary urine
Urinary infections: static in the urine is a source for bacterial growth
Escherichia Coli
Urinary reflux
EXERCISE:
Improves the appetite
Increases GI tract tone
Facilitates peristalsis
IMMOBILITY:
constipation
PSYCHONEUROLOGIC:
Apathetic
Withdrawn
Regression
Anger
Aggressive
Problem solving, decision making
✔✔Pressure injuries can be caused by what? - ✔✔Immobility
✔✔Safe Transfer of Patients - ✔✔work with assitance, Low and wide increases stability,
face direction of movement, maintain equilibrium by keeping gravity in support base.
balance weight between arms and legs, leverage, rolling, and pivoting have a less
safety risk than lifting, reduce friction
✔✔When transferring a patient from bed to wheelchair, what side do we place the
wheelchair on? - ✔✔Patients strong side so that they can assist you
✔✔*Transfer to Wheelchair* - ✔✔1. Do initial steps.
2. Place wheelchair on resident's unaffected side. Brace firmly against side of bed
3. Assist resident to sit on edge of bed. Encourage resident to sit for a few seconds to
become steady, check for dizziness.
4. Stand in front of resident and and apply gait belt around residents abdomen.
5. Grasp the gait belt securely on both sides of resident
6. Ask resident to place his hands on your upper arms.
7. On the count of three, help resident into a standing position by straightening your
knees.
8. Allow resident to gain balance, check for dizziness.
9. Move your feet 18 inches apart and slowly turn resident.
, 10. Lower resident into wheelchair by bending your knees and leaning forward.
11. Align resident's body and position foot rests.Remove gait belt
12. Do final steps.
✔✔What scale do we use to assess for fall precautions? - ✔✔Morse fall scale
✔✔Fall Prevention Strategies - ✔✔1. Install rails in the bathroom
2. Remove throw rugs
3. Remove clutter & cords in walkways
4. Educate proper use of assist devices
5. Adequate lighting
6. Wear glasses & hearing aids
7. Avoid drugs & ETOH
✔✔Nurse should utilize ______, _______, and ________ with patients who have a risk
for falling. - ✔✔ID band, non skid shoes or socks, and ambulation orders
✔✔What are some safety strategies that can be used with a patient that is a fall risk? -
✔✔Bed alarm
Observe patient at all times (nurses station buddy)
Bed low and locked
Personal items within reach
Call light available at all times
Answer their call light promptly
✔✔vital signs - ✔✔Measurements of the body's most basic functions and useful in
detecting or monitoring medical problems.
✔✔When must vital signs be assessed? - ✔✔New patient, patient status q4h, q8h, etc.,
worsening condition or new condition present, prior to patient transfer or discharge.
✔✔Basic ranges for vital signs - ✔✔Temperature= 98.6 F
Blood pressure= 120/80
Pulse= 60-100 beat/min
Respirations= 16-20 breaths/min
✔✔Thermometer locations - ✔✔Axillary- armpit
oral- mouth
rectal- anus
tympanic- ear
Temporal- forehead
✔✔Where is the most accurate place to check for core temperature? - ✔✔Rectal
SOLUTIONS GRADED A+
✔✔Airborne precautions PPE - ✔✔negative air flow room (airborne infection isolation
room)
N95 respirator
Gown
Gloves
Hand washing
✔✔contact precautions are used when? - ✔✔measures taken to prevent the spread of
diseases transmitted by the physical transfer of pathogens to a susceptible host's body
surface
✔✔Donning PPE - ✔✔Hand Hygiene!
1. gown
2. mask
3. goggles
4. gloves
" From Bottom UP (hands in the air)"
✔✔Doffing PPE - ✔✔1. Gloves
2. Gown
3. Goggles
4. Mask
Remove the most soiled to the least soiled
✔✔Proper body mechanics when lifting and moving a patient include
A. maintaining a slight curvature of your back
B. using the muscles of your lower back to lift
C. keeping the weight as close to you as possible
D. twisting at the waist when moving a patient around a corner - ✔✔C. Keeping the
weight as close to you as possible
✔✔Proper body mechanics - ✔✔Keep back straight, bend at knees, keep wide stance,
and keep objects close to body.
Use your knees not your back
No twisting
Raise the bed to safe working height
✔✔Bed Making Procedure while patient is in bed - ✔✔
✔✔Bed Making Procedure - ✔✔1. Carefully unfold sheet on bed
2. Tuck in all four corners of first sheet as hospital corners ensuring no wrinkles
,3. Apply second sheet ensuring only the corner is tucked, not the sides (mitered corner)
4. Apply blanket in the same manner
5. Fold top down
6. Pillow
✔✔What position must the bed be in before leaving the room? - ✔✔Low and locked.
✔✔Patient Positioning - ✔✔Supine: face up
Prone: the person lies on the abdomen with the head turned to the side
Low Fowlers or Semi-Fowlers: 30 degree angle
Fowler's: 45-60 degree angle
High Fowlers: 90 degree angle
Sims
Trendelenburg
Reverse Trendelenburg
Lithotomy
Lateral
✔✔When do we use high Fowler's position? - ✔✔Patient is eating or NG tube insertion
✔✔Effects of Immobility - ✔✔MUSCOSKELETAL:
Disuse osteoporosis: without weight bearing the bone demineralize and become spongy
Disuse atrophy: decrease in size looses normal function
Contractures: permanent shortening of the muscle
Stiffness and pain in the joints- ankylosis
CARDIOVASCULAR:
Diminished cardiac reserve
Increased use of Vasalva maneuver
Orthostatic (postural) hypo tension
Venous vasodilation and stasis
Dependent edema
Thrombus formation
Thrombophlebitis (impaired venous return, hypercoagulability, injury to a blood vessel)
Thrombus (clot)
Embolus
RESPIRATORY:
Decreased respiratory movement
Shallow respirations and decreased vital capacity
Pooling of secretions
Hypostatic pneumonia
Atelectasis
METABOLIC:
Decreased metabolic rate
Basal metabolic rate
Negative nitrogen balance
Anabolism/catabolism
,Anorexia
Negative calcium balance
URINARY:
Urinary stasis: lack of gravity
Renal calculi: Increase calcium salt
Urine become alkaline
Urinary retention accumulation of urine
Urinary incontinence: involuntary urine
Urinary infections: static in the urine is a source for bacterial growth
Escherichia Coli
Urinary reflux
EXERCISE:
Improves the appetite
Increases GI tract tone
Facilitates peristalsis
IMMOBILITY:
constipation
PSYCHONEUROLOGIC:
Apathetic
Withdrawn
Regression
Anger
Aggressive
Problem solving, decision making
✔✔Pressure injuries can be caused by what? - ✔✔Immobility
✔✔Safe Transfer of Patients - ✔✔work with assitance, Low and wide increases stability,
face direction of movement, maintain equilibrium by keeping gravity in support base.
balance weight between arms and legs, leverage, rolling, and pivoting have a less
safety risk than lifting, reduce friction
✔✔When transferring a patient from bed to wheelchair, what side do we place the
wheelchair on? - ✔✔Patients strong side so that they can assist you
✔✔*Transfer to Wheelchair* - ✔✔1. Do initial steps.
2. Place wheelchair on resident's unaffected side. Brace firmly against side of bed
3. Assist resident to sit on edge of bed. Encourage resident to sit for a few seconds to
become steady, check for dizziness.
4. Stand in front of resident and and apply gait belt around residents abdomen.
5. Grasp the gait belt securely on both sides of resident
6. Ask resident to place his hands on your upper arms.
7. On the count of three, help resident into a standing position by straightening your
knees.
8. Allow resident to gain balance, check for dizziness.
9. Move your feet 18 inches apart and slowly turn resident.
, 10. Lower resident into wheelchair by bending your knees and leaning forward.
11. Align resident's body and position foot rests.Remove gait belt
12. Do final steps.
✔✔What scale do we use to assess for fall precautions? - ✔✔Morse fall scale
✔✔Fall Prevention Strategies - ✔✔1. Install rails in the bathroom
2. Remove throw rugs
3. Remove clutter & cords in walkways
4. Educate proper use of assist devices
5. Adequate lighting
6. Wear glasses & hearing aids
7. Avoid drugs & ETOH
✔✔Nurse should utilize ______, _______, and ________ with patients who have a risk
for falling. - ✔✔ID band, non skid shoes or socks, and ambulation orders
✔✔What are some safety strategies that can be used with a patient that is a fall risk? -
✔✔Bed alarm
Observe patient at all times (nurses station buddy)
Bed low and locked
Personal items within reach
Call light available at all times
Answer their call light promptly
✔✔vital signs - ✔✔Measurements of the body's most basic functions and useful in
detecting or monitoring medical problems.
✔✔When must vital signs be assessed? - ✔✔New patient, patient status q4h, q8h, etc.,
worsening condition or new condition present, prior to patient transfer or discharge.
✔✔Basic ranges for vital signs - ✔✔Temperature= 98.6 F
Blood pressure= 120/80
Pulse= 60-100 beat/min
Respirations= 16-20 breaths/min
✔✔Thermometer locations - ✔✔Axillary- armpit
oral- mouth
rectal- anus
tympanic- ear
Temporal- forehead
✔✔Where is the most accurate place to check for core temperature? - ✔✔Rectal
