NURS 10A - Exam 2 Questions

The patient is admitted with a large stage IV pressure ulcer on his coccyx. After comparing the benefits of the following support surfaces, the nurse would choose which of the following as most appropriate for this patient?

Air-fluidized bed

An appropriate procedure to use when moving a patient up in bed is for the nurse to:

start by flexing the patient's knees and hips.

For cast removal, which of the following instructions should the nurse provide to the patient?

An enzyme wash may be applied to intact skin.

Handwashing with soap and water is:

necessary for hand hygiene if hands are visibly soiled.

The patient requires a support surface to help prevent pressure ulcers. He has a large open wound on his leg that is dressed daily. The nurse must choose which support surface would be most appropriate. What does the nurse realize when comparing the different types of support surfaces?

Air mattresses reduce shear and friction.

The patient is admitted to the unit with a stage III pressure ulcer. When the different types of support surfaces are compared, which would be most therapeutic for this patient?

Air-fluidized bed

What is the most important factor in preventing and treating pressure ulcers?

Frequent repositioning of the patient

The patient is brought into the emergency department after falling on the ice in her driveway. She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used?

Buck's extension

According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?

Chlorhexidine

What should the nurse do to break the chain of infection at the reservoir level?

Change a soiled dressing.

Which type of traction does the nurse anticipate will be used for an adult patient with a fractured humerus?

Dunlop's traction

While ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first?

Ease the patient down to the floor.

When the four gaits listed below are compared, which is the most stable of the crutch gaits?

Four-point gait

To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse do?

Have the patient put on shoes with nonskid soles.

Of the following problems that may occur with the use of an air-fluidized bed, which is of greatest concern to the nurse?

Insensible fluid loss

Which of the following measures is appropriate when a nurse is washing his or her hands?

Lather for at least 15 to 20 seconds.

The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what?

Orthostatic hypotension

Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position?

Orthostatic hypotension

To assist the patient to a sitting position on the side of the bed, what should the nurse do first?

Raise the head of the bed 30 degrees.

The nurse is caring for a patient who has just been treated for a broken leg. The nurse needs to teach the patient how to use crutches. Which crutch gait is most appropriate for this patient?

Three-point gait

The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?

The wider the base of support, the greater the stability of the nurse.

What is the primary purpose for the use of a support surface?

To reduce pressure

For patients with which of the following conditions should the nurse implement airborne precautions?

Tuberculosis

A patient is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

Turning the patient every 2 hours and providing a low-air-loss mattress

A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is the correct technique for the nurse to use in teaching the patient?

Use the cane on the right side, with the cane moving forward first.

The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which would be the best technique for transferring the patient?

Using three nurses and a slide board

Antiembolic stockings (TEDs) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to:

apply external pressure.

An appropriate technique for the nurse to implement for a patient who is being placed in traction is to:

assess neurovascular status every 1 to 2 hours for the first day.

When teaching the use of a three-point crutch gait, the nurse should instruct the patient to move:

both crutches and the affected leg first, then the stronger leg.

The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute:

contact precautions.

The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should:

frequently assess the patient and turn him more frequently.

Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the:

gown.

When caring for patients, the nurse understands that the single most important technique to prevent and control the transmission of infection is:

hand hygiene.

The patient has been using crutches for the past 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are:

handgrip does not allow for elbow flexion.

The nurse understands that the priority nursing action needed when medical asepsis is used includes:

handwashing.

An appropriate way for the nurse to measure a patient for crutches is to:

have a space of two to three fingers between the top of the crutch and the axilla.

A nurse encourages a patient to prevent venous stasis by:

increasing early ambulation.

When using an SCD, the nurse should:

leave a two-finger space between the patient's leg and the compression stocking.

For a patient who is to be placed in Russell's traction, the nurse prepares the:

lower extremities.

A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The nurse should:

medicate the patient with a prescribed analgesic before moving.

The most prevalent and debilitating occupational health hazard among nurses is:

musculoskeletal disorders.

When preparing to move a patient in bed, the nurse should:

raise the bed to a comfortable working height.

The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should:

raise the head of the bed and allow a few minutes before dangling.

An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to:

repeat each action five times during the exercise.

When teaching cast care, the nurse instructs the patient to:

report changes in sensation or mobility to the area.

An expected outcome of cast application that the nurse evaluates is:

slight edema, soreness, and limited range of motion.

A nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to follow is:

tighten the stomach muscles and pelvis.

An air-suspension bed is contraindicated for the patient with:

traction.

While in Buck's extension traction, the patient may be positioned on the back:

turning to the unaffected side for 10- to 15-minute periods.

The patient is admitted with mumps. The nurse knows that he or she will have to:

wear a mask when closer than 3 feet to the patient.