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