final exam pn 1006 UPDATED ACTUAL Questions and CORRECT Answers
reposition the patient at least eveey 2 hours The nurse is caring for a patient with a small chronic pressure ulcer on the ankle
what can be assigned to the health care assistant
an elderly patient with mobility issues which of the following patients would be at most risk to develop a pressure ulcer?
an elderly patient with mobility issues , a diabetic patient with properly controlled
blood sugars, a patient receiving physiotherapy following knee replacement,
middle aged woman with lupus who is having back surgery but is ambulatory
full thickness skin loss from the surface down to the fascia what assessment data would a nurse see to support the ID of a stage 3 pressure
ulcer
malnourished homeless patient with nasogastric tube The nurse is caring for four patients at risk for impaired skin integrity which patient
who is bedridden need most frequent assessment and possible intervention?
a malnourished, homeless patient with nasogastric tube who is bed ridden, a
college football player with bilateral long leg casts after motorcycle accident, an
elderly female ambulating after hip replacement surgery, a school age child
recovering from a tonsillectomy and adenoidectomy
place a piece of different coloured tape on each pill an older adult who lives alone takes three different white flat unscored
bottle to differentiate the medication medication every day. He has trouble remembering if he has taken the correct pill
at the correct time. What Strategy would be best help this patient maintain
independence and safety in taking his medications?
place a piece of different colored tape on each pill bottle to differentiate the
medication, take th medications out of the bottles and place them in a pill holder,
have a neighbor give the patient his pills once a day , ask the patient how he
wants to identify the medications
8 am, 2pm, 8pm, and 2am which schedule would the nurse select to achieve a therapeutic level if the
medication if the medication is prescribed for administration 4 times a day?
8am, 10 am , 2pm, 8pm; 10am,2pm, 6pm, 8pm;10 am,noon, 4pm, 6pm; 8am 2pm
8pm and 2am
clarify the order with the physician who wrote it. the nurse is having difficulty reading a medication order what action should they
take
clarify the administration frequency whether the a prescription reads " aspirin 325 mg 2 tablets orally for pain " what action should
medication should be PRN or standing the nurse take when the patient has pain ?
record the time administered and the nurses name The nurse needs to document a PRN medication that has just been administered
immediately after administration what technique does the nurse use
informing the nurse of the BM The nurse needs to administer a rectal suppository to a patient to treat
constipation which action may the nurse assign to the health care assistant ?
confirming the medication on the medication administration record, notifying the
patients physician of the suppository results, documenting the admin of a
suppository after insertion, informing the nurse of the BM
, the allergy history the nurse prepares a medication for a patient 1 hour after admission. What
information about the patient is the nurses priority assessment before the initial
administration of medication?
the diet history, any drug tolerance, any allergy history , the surgical history
establish the patients ability to participate and cooperate The nurse teaches the patient progressive self relaxation techniques. Which
should the nurse implement first?
direct the patient to envision sailing on a sailboat, instruct the patient to increase
respiratory rate and depth, establish the patients ability to participate and
cooperate, darken the patients room significantly and close the door
assess for pain anxiety and discomfort the nurse massages the patient to promote relaxation. Which is suitable
intervention for the patient to implement during the massage?
use the friction technique over the spine, assess for pain, anxiety and discomfort,
instruct the patient to sit upright and forward , knead the patients scalp with warm
lotion
encourage controlled breathing a patient is receiving as much opioid analgesia as the prescription allows and
continues to have difficulty sleeping at night because of pain. Which should the
nurse implement to relieve pain and improve sleep? encourage controlled
breathing, provide a glass of wine at bedtime, administer more analgesia and
inform the physician in the morning, increase fluids and reposition the patient
remove the compress and assess the affected area the patient complains of a slight burning- like pain and numbness on the skin
under a cold compress. Which action should the nurse take immediately? reassure
the patient that some numbness is expected, assess the entire patient before
continuing the treatment, remove the compress and assess the affected area,
provide a warm blanket for the patients treatment
False A braden scale of 8 would indicate the patient is at low risk for skin breakdown:
True or False
true poor sensory perceptioni decreases the patients ability to feel the sensation of
pressure or discomfort: true or false ?
true the rubbing of the tissue against a surface is called friction; it abrades the top
layer of the skin, which makes tissue susceptible to pressure injury true or false ?
true respiratory depression maybe a sign of toxicty with opioid medications true or
false
true adverse drug events are unintended undesirable and often unpredictable true or
false
true distractions when administering medications can be a cause of medication errors
true or false
false in some instances it is acceptable to sign for a medication before it has been
given true or false
reposition the patient at least eveey 2 hours The nurse is caring for a patient with a small chronic pressure ulcer on the ankle
what can be assigned to the health care assistant
an elderly patient with mobility issues which of the following patients would be at most risk to develop a pressure ulcer?
an elderly patient with mobility issues , a diabetic patient with properly controlled
blood sugars, a patient receiving physiotherapy following knee replacement,
middle aged woman with lupus who is having back surgery but is ambulatory
full thickness skin loss from the surface down to the fascia what assessment data would a nurse see to support the ID of a stage 3 pressure
ulcer
malnourished homeless patient with nasogastric tube The nurse is caring for four patients at risk for impaired skin integrity which patient
who is bedridden need most frequent assessment and possible intervention?
a malnourished, homeless patient with nasogastric tube who is bed ridden, a
college football player with bilateral long leg casts after motorcycle accident, an
elderly female ambulating after hip replacement surgery, a school age child
recovering from a tonsillectomy and adenoidectomy
place a piece of different coloured tape on each pill an older adult who lives alone takes three different white flat unscored
bottle to differentiate the medication medication every day. He has trouble remembering if he has taken the correct pill
at the correct time. What Strategy would be best help this patient maintain
independence and safety in taking his medications?
place a piece of different colored tape on each pill bottle to differentiate the
medication, take th medications out of the bottles and place them in a pill holder,
have a neighbor give the patient his pills once a day , ask the patient how he
wants to identify the medications
8 am, 2pm, 8pm, and 2am which schedule would the nurse select to achieve a therapeutic level if the
medication if the medication is prescribed for administration 4 times a day?
8am, 10 am , 2pm, 8pm; 10am,2pm, 6pm, 8pm;10 am,noon, 4pm, 6pm; 8am 2pm
8pm and 2am
clarify the order with the physician who wrote it. the nurse is having difficulty reading a medication order what action should they
take
clarify the administration frequency whether the a prescription reads " aspirin 325 mg 2 tablets orally for pain " what action should
medication should be PRN or standing the nurse take when the patient has pain ?
record the time administered and the nurses name The nurse needs to document a PRN medication that has just been administered
immediately after administration what technique does the nurse use
informing the nurse of the BM The nurse needs to administer a rectal suppository to a patient to treat
constipation which action may the nurse assign to the health care assistant ?
confirming the medication on the medication administration record, notifying the
patients physician of the suppository results, documenting the admin of a
suppository after insertion, informing the nurse of the BM
, the allergy history the nurse prepares a medication for a patient 1 hour after admission. What
information about the patient is the nurses priority assessment before the initial
administration of medication?
the diet history, any drug tolerance, any allergy history , the surgical history
establish the patients ability to participate and cooperate The nurse teaches the patient progressive self relaxation techniques. Which
should the nurse implement first?
direct the patient to envision sailing on a sailboat, instruct the patient to increase
respiratory rate and depth, establish the patients ability to participate and
cooperate, darken the patients room significantly and close the door
assess for pain anxiety and discomfort the nurse massages the patient to promote relaxation. Which is suitable
intervention for the patient to implement during the massage?
use the friction technique over the spine, assess for pain, anxiety and discomfort,
instruct the patient to sit upright and forward , knead the patients scalp with warm
lotion
encourage controlled breathing a patient is receiving as much opioid analgesia as the prescription allows and
continues to have difficulty sleeping at night because of pain. Which should the
nurse implement to relieve pain and improve sleep? encourage controlled
breathing, provide a glass of wine at bedtime, administer more analgesia and
inform the physician in the morning, increase fluids and reposition the patient
remove the compress and assess the affected area the patient complains of a slight burning- like pain and numbness on the skin
under a cold compress. Which action should the nurse take immediately? reassure
the patient that some numbness is expected, assess the entire patient before
continuing the treatment, remove the compress and assess the affected area,
provide a warm blanket for the patients treatment
False A braden scale of 8 would indicate the patient is at low risk for skin breakdown:
True or False
true poor sensory perceptioni decreases the patients ability to feel the sensation of
pressure or discomfort: true or false ?
true the rubbing of the tissue against a surface is called friction; it abrades the top
layer of the skin, which makes tissue susceptible to pressure injury true or false ?
true respiratory depression maybe a sign of toxicty with opioid medications true or
false
true adverse drug events are unintended undesirable and often unpredictable true or
false
true distractions when administering medications can be a cause of medication errors
true or false
false in some instances it is acceptable to sign for a medication before it has been
given true or false
