Medical-Surgical Nursing Concepts
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1. Patricia is an RN working at a rehabilitation center and witnesses a nurse aid
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n, struggling to lift and reposition an elderly, bed ridden patient. She explains
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n, to the nurse aide that there is a No Lift Policy in place in the establishment.
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What does this policy entail
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: ANS>> The concept of a no-lift policy is a pledge from adminis- trators that
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proper equipment, adequately maintained and in sufficient numbers, will
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n, be available to care providers to reduce the risks associated with manual
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n, patient handling n,
2. Immobility effects multiple body systems.What are some interventions that
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n, you can implement to decrease these effects? Select all that apply.
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A. Utilizing waffle mattress to reduce the need for repositioning
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,B. Teds/SCDs
C. Rubbing reddened areas n, n,
D. Limiting fluid intake n, n,
E. ROM exercises n,
: ANS>> : B and E n, n,
Rational:
-A is incorrect because regardless of implemented mattress, positioning should be
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n, every 2 hours n, n,
-C is incorrect.You should not rub at reddened areas.This increases the risk for skin
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n, break.
-D is incorrect.You should encourage proper hydration to promote well hydrated
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and healthy skin.
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3. True or False: Nurses should do skin assessments once a week
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: ANS>> False
Rational: Nurses should do full skin assessments a minimum of once per shift.
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4. A pt goes to the ER for swelling and pain in her right calf.The PT states that
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n, it occurred after she accidentally cut herself. Based on her symptoms, what
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n , skin condition might the nurse suspect the patient has
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: ANS>> Cellulitis.
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, Cellulitis is inflammation of the skin and subq tissue.
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5. Pt A is admitted from a nursing home with a stage 3 pressure ulcer.
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n,When creating his plan of care, who else would be involved besides the
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n, primary care physician n, n,
: ANS>> Wound care nurse, Dietician, Physical therapist. OT can also be
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included, however they deal more with fine motor skills.
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6. An 85 year old woman is admitted to the hospital. When doing the
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n, initial assessment, what are some factors that you know put her at risk for
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n, pressure injuries n,
: ANS>> -if the pt is immobile n, n, n, n,
-if the pt is incontinent
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