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ACTUAL EXAM 180 QUESTIONS AND CORRECT DE
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TAILED ANSWERS WITH RATIONALES ALREADY G
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RADED A+ GALEN COLLEGE OF NURSING g g g g g
Immobility effects multiple body systems. What are some int
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erventions that you can implement to decrease these effect
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s? Select all that apply.
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A. Utilizing waffle mattress to reduce the need for r
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epositioning
B. Teds/SCDs
C. Rubbing reddened areas g g
D. Limiting fluid intake g g
E. ROM exercises - ANSWER >>>>ANSWER: B and E
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Rational:
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A is incorrect because regardless of implemented mattress,
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positioning should be every 2 hours g g g g g
-
C is incorrect. You should not rub at reddened areas. This in
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creases the risk for skin break.
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-
D is incorrect. You should encourage proper hydration to pr
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omote well hydrated and healthy skin.
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True or False: Nurses should do skin assessments once a w
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eek. - ANSWER >>>>False
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,Rational: Nurses should do full skin assessments a minimu
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m of once per shift.
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A pt goes to the ER for swelling and pain in her right calf. T
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he PT states that it occurred after she accidentally cut hers
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elf. Based on her symptoms, what skin condition might the
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nurse suspect the patient has? - ANSWER
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>>>>Cellulitis.
Cellulitis is inflammation of the skin and subq tissue.
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Pt A is admitted from a nursing home with a stage 3 pressur
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e ulcer. When creating his plan of care, who else would be i
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nvolved besides the primary care physician? -
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ANSWER >>>>Wound care nurse, Dietician, Physical ther
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apist. OT can also be included, however they deal more wit
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h fine motor skills.
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An 85 year old woman is admitted to the hospital. When doi
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ng the initial assessment, what are some factors that you kn
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ow put her at risk for pressure injuries? - ANSWER
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>>>>-if the pt is immobile g g g g
-if the pt is incontinent
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-if the pt has comorbidities such as diabetes or PVD
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-if the pt is malnourished or dehydrated
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-if the pt suffers from decreased sensory perception
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The nurse notices a localized red area that is nonblanchabl
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e on the the patient's coccyx. What stage
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,pressure injury is this recognized as? - ANSWER
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>>>>Stage 1 g
Stage 1 pressure injury means the skin is intact with a locali
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zed area of nonblanchable erythema (fancy word for rednes
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s).
A pt asks you why what he eats has anything to do with wou
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nd healing. What is your response? - ANSWER
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>>>>Successful healing of pressure injuries depends on ad g g g g g g g
equate intake of calories protein, vitamins, minerals and wat
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er.
After receiving shift report, the night nurse looks at the lab v
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alues for a patient with cellulitis. What abnormal lab values
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might you see? - ANSWER >>>>-WBC - elevated
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-Creatinine- elevated g
-Bicarbonate- low g
-Albumin- low g
-Calcium- low g
What pain rating scale might you use for a child or a nonver
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bal patient? - ANSWER >>>>Wong Baker-Faces Scale
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When assessing a pt's pain. He tells you that the pain come
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s and goes. What part of the pain assessment is he describi
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ng?
A. Quality
B. Intensity
, C. Onset and Duration g g
D. Location - ANSWER >>>>C. Onset and Duration g g g g g g
When explaining to a pt what an intraspinal analgesic the pt
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states "So the medication will be given to me through the I
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V in my arm." How would you correct him? -
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ANSWER >>>>instraspinal analgesics are delivered into t
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he epidural space of the spine, also known as the subarach
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noid space. g
When adjusting a TENs machine on a patient, how do you k
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now the conduction of electricity has reached a therapeutic l
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evel? - g
ANSWER >>>>The patient will verbalize feeling a sensatio
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n of pins and needles.
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Your pt verbalizes a pain of 2/10 and requests their dose of
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morphine. How would you educate your pt? - ANSWER
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>>>>Morphine is an opioid analgesic used for moderate to s g g g g g g g g g
evere pain. g
What is the most common side effect of analgesic use and h
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ow can we prevent it? - ANSWER >>>>Constipation.
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A high fiber diet, plenty of fluids, and stool softeners are pro
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phylactic measures. g
The patient is undergoing surgery to fix a cleft palate. What
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type of surgery is this considered? - ANSWER
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>>>>Constructive