RNSG 1105 COMPREHENSIVE EXAM UPDATED QUESTIONS
AND SOLUTIONS RATED A+
✔✔Restraints most commonly used to: - ✔✔1. position and protect pt during treatments
and to maintain ongoing care (prevent pulling on catheter, dressings, NG tube, stitches,
IV tubing)
2. protect pts who get confused and wander
3. protect pts who are combative and agitated and may cause harm to self or others
✔✔Physiologic hazards associated with restraints - ✔✔suffocation from entrapment
impaired circulation
altered skin integrity
diminished muscle & bone mass
fractures
altered nutrition & hydration
aspiration & breathing difficulties
incontinence
changes in mental status
✔✔Safety Measure Guidelines in Applying Restraints - ✔✔1. Must obtain a HCP current
order
2. Each original restraint order is limited to: 8 hours for adults, 2 hours for 9-17 years, 1
hour for children under 9 years old
3. The pt and family must be told the reasons for use
4. Use sparingly and only after documented alternatives tried. Discontinue ASAP.
4. Least restrictive should be tried first using the proper type & size
5. After application, evaluate pt for signs of injury and readiness for discontinuation
6. Remove restraint at least every 2 hrs to reposition, provide toileting and comfort
measures, and evaluate.
7. Documentation as per facility specs - bx that needed the application, alt measures
tried, condition of body part, type of restraint
✔✔What techniques should the nurse utilize to avoid musculoskeletal strain and lift
injuries to self? - ✔✔arrange for adequate help
use pt handling equipment such as height adjustable beds, lifts, friction-reducing slide
sheets, and air-assisted devices
encourage pt to help as much as possible
take position close to the pt
tighten abdominal muscles and keep back, neck, pelvis, and feet aligned
bend at knees; keep feet wide apart
use arms and legs not back
slid pt toward your body
perform manual lifting as a last resort
✔✔Ensuring safe patient handling - ✔✔explain to the pt what will be done
, if needed, administer prescribed analgesic in advance
elevate bed to proper height and lock wheels
position pt in proper body alignment
protect from injury while being moved
avoid friction on pt's skin while being moved
move your body & the pt's in a smooth rhythmic motion
✔✔Supine position - ✔✔lying on back, facing upward
✔✔Fowler's and semi-Fowler's position - ✔✔Laying on back with head of bed elevated
60 degrees for Fowler's and 30-45 degrees for semi-Fowler's
✔✔Lateral position - ✔✔side lying position
✔✔Sims position - ✔✔lying on left side with right knee drawn up and with left arm drawn
behind, parallel to the back
✔✔Prone position - ✔✔lying face down
✔✔Assessment prior to ROM exercises - ✔✔medical diagnosis
capabilities
movements not allowed
does pt take pain meds prior to activity
ability to understand instructions
if help is needed, to move heavy or helpless pts
✔✔Guidelines for performing ROM - ✔✔1. teach pt what exercise, why & how.
2. Avoid overexertion and exercise to the point that pt develops fatigue
3. avoid neck hyperextension.
4. Start gradually and movements should be smooth & rhythmic.
5. Move each joint until there is resistance, but not pain.
6. Use a variety of support measures when exercising.
7. Return joint to neutral position
8. Keep friction to a minimum
9. Perform ROM twice a day and do each exercise 2-5 times. HR & breathing will
increase
10. Rate should return to normal in 3 minutes
11. Move to active ROM as soon as condition is better.
✔✔Assessing patient's tolerance of thermal therapy - ✔✔the skin, look for any open
areas
the neurological system for sensation
the pt's mental status
identification of conditions that contraindicate heat or cold therapy
the condition of the equipment being used
AND SOLUTIONS RATED A+
✔✔Restraints most commonly used to: - ✔✔1. position and protect pt during treatments
and to maintain ongoing care (prevent pulling on catheter, dressings, NG tube, stitches,
IV tubing)
2. protect pts who get confused and wander
3. protect pts who are combative and agitated and may cause harm to self or others
✔✔Physiologic hazards associated with restraints - ✔✔suffocation from entrapment
impaired circulation
altered skin integrity
diminished muscle & bone mass
fractures
altered nutrition & hydration
aspiration & breathing difficulties
incontinence
changes in mental status
✔✔Safety Measure Guidelines in Applying Restraints - ✔✔1. Must obtain a HCP current
order
2. Each original restraint order is limited to: 8 hours for adults, 2 hours for 9-17 years, 1
hour for children under 9 years old
3. The pt and family must be told the reasons for use
4. Use sparingly and only after documented alternatives tried. Discontinue ASAP.
4. Least restrictive should be tried first using the proper type & size
5. After application, evaluate pt for signs of injury and readiness for discontinuation
6. Remove restraint at least every 2 hrs to reposition, provide toileting and comfort
measures, and evaluate.
7. Documentation as per facility specs - bx that needed the application, alt measures
tried, condition of body part, type of restraint
✔✔What techniques should the nurse utilize to avoid musculoskeletal strain and lift
injuries to self? - ✔✔arrange for adequate help
use pt handling equipment such as height adjustable beds, lifts, friction-reducing slide
sheets, and air-assisted devices
encourage pt to help as much as possible
take position close to the pt
tighten abdominal muscles and keep back, neck, pelvis, and feet aligned
bend at knees; keep feet wide apart
use arms and legs not back
slid pt toward your body
perform manual lifting as a last resort
✔✔Ensuring safe patient handling - ✔✔explain to the pt what will be done
, if needed, administer prescribed analgesic in advance
elevate bed to proper height and lock wheels
position pt in proper body alignment
protect from injury while being moved
avoid friction on pt's skin while being moved
move your body & the pt's in a smooth rhythmic motion
✔✔Supine position - ✔✔lying on back, facing upward
✔✔Fowler's and semi-Fowler's position - ✔✔Laying on back with head of bed elevated
60 degrees for Fowler's and 30-45 degrees for semi-Fowler's
✔✔Lateral position - ✔✔side lying position
✔✔Sims position - ✔✔lying on left side with right knee drawn up and with left arm drawn
behind, parallel to the back
✔✔Prone position - ✔✔lying face down
✔✔Assessment prior to ROM exercises - ✔✔medical diagnosis
capabilities
movements not allowed
does pt take pain meds prior to activity
ability to understand instructions
if help is needed, to move heavy or helpless pts
✔✔Guidelines for performing ROM - ✔✔1. teach pt what exercise, why & how.
2. Avoid overexertion and exercise to the point that pt develops fatigue
3. avoid neck hyperextension.
4. Start gradually and movements should be smooth & rhythmic.
5. Move each joint until there is resistance, but not pain.
6. Use a variety of support measures when exercising.
7. Return joint to neutral position
8. Keep friction to a minimum
9. Perform ROM twice a day and do each exercise 2-5 times. HR & breathing will
increase
10. Rate should return to normal in 3 minutes
11. Move to active ROM as soon as condition is better.
✔✔Assessing patient's tolerance of thermal therapy - ✔✔the skin, look for any open
areas
the neurological system for sensation
the pt's mental status
identification of conditions that contraindicate heat or cold therapy
the condition of the equipment being used
