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NUR242/ NUR 242 EXAM 1: MED-SURG | GUIDE
WITH QUESTIONS AND VERIFIED ANSWERS|
100% CORRECT- GALEN
QUESTION: What does a No Lift Policy entail in a
rehabilitation center?
Answer: 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? 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
QUESTION: What interventions can decrease the effects of
immobility on multiple body systems?
Answer: 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: 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
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the risk for skin break. -D is incorrect. You should encourage proper hydration to promote well hydrated and healthy skin.
QUESTION: Is it true that nurses should do skin assessments
once a week?Answer: True or False: Nurses should do skin assessments once
a week. False Rational: Nurses should do full skin assessments a
minimum of once per shift.
QUESTION: What skin condition might a nurse suspect in a
patient with swelling and pain in the right calf after a cut?
Answer: 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? Cellulitis. Cellulitis is inflammation of the skin and subq tissue.
QUESTION: Who should be involved in creating a plan of care
for a patient with a stage 3 pressure ulcer besides the primary care physician?
Answer: 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? Wound care nurse, Dietician, Physical therapist. OT can also be included, however they deal more with fine motor skills.
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QUESTION: What factors put an 85-year-old woman at risk for
pressure injuries during an initial assessment?
Answer: 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? -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
QUESTION: What stage pressure injury is a localized,
nonblanchable red area on the coccyx recognized as?
Answer: The nurse notices a localized red area that is
nonblanchable on the the patient's coccyx. What stage pressure injury is this recognized as? Stage 1 Stage 1 pressure injury means the skin is intact with a localized area of nonblanchable erythema (fancy word for redness).
QUESTION: How should a nurse respond to a patient asking
why diet affects wound healing?
Answer: A pt asks you why what he eats has anything to do with
wound healing. What is your response? Successful healing of pressure injuries depends on adequate intake of calories protein, vitamins, minerals and water.
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QUESTION: What abnormal lab values might a night nurse see
in a patient with cellulitis?
Answer: After receiving shift report, the night nurse looks at the
lab values for a patient with cellulitis. What abnormal lab values might you see? -WBC - elevated -Creatinine- elevated - Bicarbonate- low -Albumin- low -Calcium- low
QUESTION: What pain rating scale might a nurse use for a
child or nonverbal patient?
Answer: What pain rating scale might you use for a child or a
nonverbal patient? Wong Baker-Faces Scale
QUESTION: What part of the pain assessment is a patient
describing when they say the pain comes and goes?
Answer: 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 C. Onset and Duration
QUESTION: How should a nurse correct a patient who thinks
an intraspinal analgesic is given through an IV in the arm?
Answer: 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? instraspinal