RNSG 1513 Sherpath

The registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure injuries. Which statement by the nursing student indicates effective learning?

"I should educate the patient about the signs of wound infection." "I should discuss reactive surfaces that may increase pressure to the wound."

Which statement by a patient indicates the need for further teaching regarding diaphragmatic breathing?

"I should practice the exercise initially in the sitting position and then in the supine position." Patient should start in supine before moving to sitting

Who should get the pneumococcal vaccine?

-65 or older -adult smokers -adult with chronic illness -resident of nursing home, long term care, prisons -younger than 2 years

What is the oxygen flow rate for a nasal cannula

1-6 L/min

What is the oxygen flow rate of nonrebreather masks

10-15 L/min

Which patient is at higher risk of motor vehicle accidents according to the CDC?

16 year old adolescent

The nurse administers an analgesic medication to a patient with a stage 4 pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic?

30-60 minutes after administration

Which size syringe is used for irrigating an open wound?

35 mL

What is the oxygen flow rate for a venturi mask

4-12 L/min

In which position would the nurse place a patient with a right lung absecess

45 degree semi fowler position with right lung down

Which intervention is no longer recommended for routine home treatment of poisoning cases

Administration of ipecac syrup

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development?

Braden scale

A parent calls the pediatrician's office frantic about a bottle of cleaner that the 2 year old son drank. Which instruction is most important for the nurse to give to the parent

Call poison control

A patient has ingested poison and is found conscious and alert. Which action by the nurse is priority

Calling the local poison control center

Flat, painless, and found on the undersurface of the foot or palm of the hand

Callus

While assessing a patient's oral cavity, the nurse observes cracked lips. Which condition does the nurse document in the patient's medical record

Cheilitis

The nurse is training a new mother on the use of the heimlich maneuver. This intervention lowers the risk of which emergency situation?

Choking

While assessing a patient's oral cavity, the nurse notes tooth decay. The finding indicates which condition?

Dental caries

When providing perineal care to a female patient, the nurse places the patient in which position?

Dorsal recumbent

Xerostomia

Dryness of the mouth caused by reduction of saliva

The nurse is assessing a patient who reports joint pain. Which type of range of motion assessed by the nurse involves saggital plane movement?

Extension, dorsiflexion

Which primary muscles is used for the abduction of the wrist joint?

Flexor carpi radialis, extensor carpi radialis brevis/longus

Which position reduces the risk of DVT?

Fowler, by improving peripheral circulation

Which activity is least appropriate for an older-adult patient's exercise program?

HIIT

On assessment, the nurse finds that the patient has bad breath. Which condition does the nurse document?

Halitosis

Which nursing measure lowers the risk of death caused by sudden infant death syndrome (SIDS)?

Having the baby sleep on the back

Which outcome is desired when the head of the bed is elevated to 60 degrees in the supported fowler position

Improves ventilation

The nurse is teaching a nursing student about various deformities of the spine. Which is true about spine deformities?

Kyphosis is the increased convexity in curvature of the thoracic spine Lordosis is the exaggeration of the anterior convex curve of the lumbar spine Scoliosis is the lateral S or C shaped spinal column with vertebral rotation

The nurse is assisting the health care provider in applying moist dressing on a patient who has pressure injuries. The nurse reviews the prescriptions for the dressing change procedure. Which rationale would explain this nursing action?

Learning the type of dressing that is to be used

A nurse finds that a patient who has urinary incontinence scores 11 on the braden scale. Which nursing action is most appropriate to prevent this patient from developing pressure injuries?

Managing moisture

Which role does vitamin A play in wound healing

Promotes wound closure

Which position prevents footdrop?

Prone

Which nursing activity is involved in evaluation to determine patient safety

Reassessing the patient for the presence of physical, social, and environmental risks

An older adult who was in a car accident and fractured their femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time?

Risk of inability to tolerate activity

trochanter roll

Rolled towel support placed against the hips and upper leg to prevent external rotation of the legs.

Which parameter would be measured to determine the protein deficiency in the patient with a wound?

Serum albumin, serum transferrin, serum prealbumin

What type of injury does a trapeze bar prevent?

Shearing from sliding across or up/down a bed

The nurse is positioning a postoperative patient to place the major portion of the body weight on the hip and shoulder. In which position does the nurse place the patient?

Side-laying

Which position reduces the risk of pressure injuries?

Side-laying

The nurse is caring for different patients. A patient with which condition may benefit from logrolling

Spinal cord injury, logrolling prevents further injury by keeping the spinal column in straight alignment

Which position reduces the risk of musculoskeletal injury?

Supine

Which statement demonstrates an understanding regarding the mechanisms of balance in the human body?

The cerebellum coordinates all voluntary movement

What is a trapeze bar used for?

To help patients transfer from bed to wheelchair and also perform upper arm exercises

Which positioning aid prevents external rotation of the hips when the patient is in the supine position

Trochanter roll

Inversion

Turning the sole of the foot inward, frontal plane

Which statement regarding orthostatic hypotension requires further learning?

Younger patients are prone to orthostatic hypotension

Lordosis

abnormal increase in the forward curvature of the lumbar spine

Scoliosis

abnormal lateral curvature of the spine

Which patient receives a red wristband?

allergies

scaling and cracking of the skin between the toes

athlete's foot

What is the order of applying a nasal cannula

attach the cannula to an oxygen source Insert nasal prongs into the patient's nostrils Adjust the lanyard so the cannula fits snugly monitor response with SpO2 Observe ears and nares for evidence of MDRPI

Halitosis

bad breath

The nurse bathes an older patient using a pack of cotton cloths that are premoistened with a surfactant cleaner and an emollient. Which bath is being given to the patient?

bag bath

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part?

bedsore, pressure sore, pressure ulcer, decubitus ulcer

Dorsiflexion

bending of the foot or the toes upward, sagittal plane

Which increase would exercise cause in the human body?

cardiac output, bmr, joint mobility

Footdrop

complication resulting from extended plantar flexion

Cone-shaped and found on the toes

corn

The removal of devitalized tissue from a wound describes which process?

debridement

hypoxemia

deficient amount of oxygen in the blood

Which element is included among the passive strategies of health promotion

enacting public sanitation legislation

Kyphosis

excessive outward curvature of the spine, causing hunching of the back.

What causes athletes foot?

fungal infection

How do you minimize suction-induced hypoxemia

hyperoxygenation via deep breathing

When caring for a patient postoperatively, which nursing intervention prevents atelectasis

incentive spirometry since it promotes deep breathing

Postural drainage, chest percussion, and suctioning are used to treat

increased mucus production

Gingivitis

inflammation of the gums

Cheilitis

inflammation of the lip

Glossitis

inflammation of the tongue

The registered nurse provides various instructions to the caregiver of an infant before discharge from the hospital. Which instruction promotes safety for the infant?

install deadbolts on exterior doors above the child's reach

The use of which restraint has been eliminated by many health care agencies because of the risk of fatal injuries

jacket

Which patient assessment finding indicates that oropharyngeal suction has been effective?

less fatigue, increased ability to expectorate, increased ability to swallow the mucus

Which type of equipment does the nurse obtain before attempting to take an unstable and weak patient out of a bathtub?

lift device

While bathing a patient, the nurse recalls that excessive massaging of the patient's calf could create which patient response

loosening of a deep vein thrombosis

Which action helps manage an apneic episode in infants?

massaging the heels

Abduction

movement away from the midline, frontal plane

Which physiologic factor would influence a patient's activity tolerance?

pain

Which demographic should not undergo chest physiotherapy?

patients on long-term steroids because it increases the risk for pathologic rib fractures.

Fungating lesion that appears on the sole of the foot

plantar wart

Which condition leads to lesions on the sole of the foot associated with a papillomavirus infection

plantar warts

Plantarflexion

point toes down, sagittal plane

In which position would the nurse place the patient to drain the posterior segment of the right middle lobe

prone with thorax and abdomen elevated

When there is a fire in the hospital, which action by the nurse is priority?

rescuing patients in immediate danger

Which factor would render older women more susceptible to fractures?

resorption and osteoporosis

Which action helps stimulate respirations in an infant?

rubbing the back

Braden scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

In which position would the nurse place the patient to drain the lateral segments of the lungs

side-lying trendelenburg

Which delivery device is used for short-term oxygen therapy and delivers oxygen concentrations from 6-12 L/min

simple face mask

In which position would the nurse place the patient to drain the apical segments of the lungs

sitting on the side of the bed

After chest physiotherapy, which intervention is beneficial for the patient who has difficulty producing a cough?

suctioning since chest physiotherapy helps mobilize secretions

When providing perineal care to a male patient, the nurse places the patient in which position?

supine

In which position would the nurse place the patient to drain the anterior segments of the right and left upper lobes

supine with head elevated

What position should a patient initially be in for diaphragmatic breathing?

supine, then sitting or standing

Which rationale explains the nurse not applying suction pressure while inserting the catheter

to avoid traumatizing the lung mucosa

Which rationale explains assisting the patient in taking deep breaths with an oxygen delivery device before nasopharyngeal suctioning?

to minimize hypoxemia after suctioning

Why is the affected lung positioned down in patients with a pulmonary abcess

to prevent the flow of secretions to the healthy lung

dental caries

tooth decay

lung apices

tops of the lungs

Pronation

turning the palm downward, occurs in the transverse plane

Eversion

turning the sole of the foot outward, frontal plane