Fundamentals/Precautions questions and answers 2023
with complete solution
how to walk up the stairs with crutches
1. Hold to rail with one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg.
3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg.
4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg.
5. Remember, the 'unaffected' leg goes up first and the crutches move with the
'affected' leg.
A menopausal client is having difficulty getting to sleep and asks what actions she
should incorporate in her daily routine to promote sleep. The nurse would encourage,
which of the below measures to promote sleep?
A: Measures to promote sleep include:
●● Exercise regularly; limit exercise at least 2 hr before bedtime.
●● Establish a bedtime routine and a regular sleep pattern.
●● Arrange the sleep environment for comfort.
●● Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
●● Limit fluids 2 to 4 hr before bedtime.
●● Engage in muscle relaxation if anxious or stressed.
List at least five (5) priority considerations when performing a sterile dressing change.
Do not cough, sneeze, or breathe heavily on/in the direction of the sterile field.
Keep the sterile field at/above the waistline
First, open the flap of the package furthest away from the sterile field.
Make sure a trash can is nearby to discard dirty items as soon as possible
Prolonged exposure to microorganisms can make a sterile item not sterile
List five (5) expected assessment findings for the older adult due to the physical
changes during aging.
Decreased skin turgor and subcutaneous fat
Thickening of finger and toenails
Decreased cardiac output and peripheral circulation
Increased blood pressure
Decreased touch, smell, taste, and reaction time
The nurse is caring for a client who has been diagnosed as hypovolemic and has been
ordered fluid replacement therapy. What lab values would indicate hypovolemia due to
dehydration and why?
Increased hematocrit → because the concentration of the HCT increases as fluid
decreases (dehydration.
Serum osmolarity increases → concentration increases to greater than 295 because
fluid is decreased.
Urine specific gravity → Increased concentration greater than 1.030.
Increased serum sodium >145 → due to hemoconcentration.
Describe the procedure to use when applying elastic stockings (TEDS).
The priority assessment should involve calf circumference measurements,
respiratory/cardiac changes/trends, peripheral pulses, and pain, warmth, and/or edema
, in the extremities.
First, perform hand hygiene, next assess peripheral circulation, calf circumference with
a tape measure on both legs, skin, and presence of edema. Turn the stockings inside to
the heel, insert the foot, turn the remainder of the stocking over the heel and up the leg.
Smooth creases or wrinkles. Remove and reassess every eight hours. Make sure
stockings are clean, dry and not too tight over the toes. Perform proper documentation
of application, removal, and assessments.
The nurse has been assigned to a post-abdominal surgery client who has also been
diagnosed with dementia. The family is concerned about pain control for the client
because the client is confused. What should the nurse include in their teaching to the
family about the pain control plan for this client?
The nurse should include that the patient's vital signs are indicative of of his pain and
are assessed frequently. The nurse should also explain the trend in behavior changes
for the patient with dementia when they are in pain. The nurse should teach about pre
medicating the patient before activities and before expected pain.
What action should a nurse implement to prevent clogging of the tube after medication
administration?
Flush the tube with 15-30 ml of water before and after each medication administration.
Flush with another 15-30 ml of sterile water after the installation of all medications.
A client's lab values indicate a serum sodium level of 150 mEq/L. How could this affect
the client's vital signs?
This causes a shift in the water which is moved outside of the cells and causes
dehydrated cells. I think it would increase the HR and BP initially and depending on the
cause. May or may not affect the temperature and RR.
Latex allergies
Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.
Order of assessment:
I-inspection
P-palpation
P-percussion
A-auscultation
Cane walking:
C-cane
O-opposite
A-affected
L-leg
Crutch walking:
Remember the phase "step up" when picturing a person going up stairs with crutches.
The good leg goes up first followed by the crutches and the bad leg. The opposite
happens going down the stairs....OR "up to heaven...down to hell"
Delegation:
RNs DO NOT delegate what they can EAT--evaluate, assess, teach
AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
with complete solution
how to walk up the stairs with crutches
1. Hold to rail with one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg.
3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg.
4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg.
5. Remember, the 'unaffected' leg goes up first and the crutches move with the
'affected' leg.
A menopausal client is having difficulty getting to sleep and asks what actions she
should incorporate in her daily routine to promote sleep. The nurse would encourage,
which of the below measures to promote sleep?
A: Measures to promote sleep include:
●● Exercise regularly; limit exercise at least 2 hr before bedtime.
●● Establish a bedtime routine and a regular sleep pattern.
●● Arrange the sleep environment for comfort.
●● Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.
●● Limit fluids 2 to 4 hr before bedtime.
●● Engage in muscle relaxation if anxious or stressed.
List at least five (5) priority considerations when performing a sterile dressing change.
Do not cough, sneeze, or breathe heavily on/in the direction of the sterile field.
Keep the sterile field at/above the waistline
First, open the flap of the package furthest away from the sterile field.
Make sure a trash can is nearby to discard dirty items as soon as possible
Prolonged exposure to microorganisms can make a sterile item not sterile
List five (5) expected assessment findings for the older adult due to the physical
changes during aging.
Decreased skin turgor and subcutaneous fat
Thickening of finger and toenails
Decreased cardiac output and peripheral circulation
Increased blood pressure
Decreased touch, smell, taste, and reaction time
The nurse is caring for a client who has been diagnosed as hypovolemic and has been
ordered fluid replacement therapy. What lab values would indicate hypovolemia due to
dehydration and why?
Increased hematocrit → because the concentration of the HCT increases as fluid
decreases (dehydration.
Serum osmolarity increases → concentration increases to greater than 295 because
fluid is decreased.
Urine specific gravity → Increased concentration greater than 1.030.
Increased serum sodium >145 → due to hemoconcentration.
Describe the procedure to use when applying elastic stockings (TEDS).
The priority assessment should involve calf circumference measurements,
respiratory/cardiac changes/trends, peripheral pulses, and pain, warmth, and/or edema
, in the extremities.
First, perform hand hygiene, next assess peripheral circulation, calf circumference with
a tape measure on both legs, skin, and presence of edema. Turn the stockings inside to
the heel, insert the foot, turn the remainder of the stocking over the heel and up the leg.
Smooth creases or wrinkles. Remove and reassess every eight hours. Make sure
stockings are clean, dry and not too tight over the toes. Perform proper documentation
of application, removal, and assessments.
The nurse has been assigned to a post-abdominal surgery client who has also been
diagnosed with dementia. The family is concerned about pain control for the client
because the client is confused. What should the nurse include in their teaching to the
family about the pain control plan for this client?
The nurse should include that the patient's vital signs are indicative of of his pain and
are assessed frequently. The nurse should also explain the trend in behavior changes
for the patient with dementia when they are in pain. The nurse should teach about pre
medicating the patient before activities and before expected pain.
What action should a nurse implement to prevent clogging of the tube after medication
administration?
Flush the tube with 15-30 ml of water before and after each medication administration.
Flush with another 15-30 ml of sterile water after the installation of all medications.
A client's lab values indicate a serum sodium level of 150 mEq/L. How could this affect
the client's vital signs?
This causes a shift in the water which is moved outside of the cells and causes
dehydrated cells. I think it would increase the HR and BP initially and depending on the
cause. May or may not affect the temperature and RR.
Latex allergies
Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.
Order of assessment:
I-inspection
P-palpation
P-percussion
A-auscultation
Cane walking:
C-cane
O-opposite
A-affected
L-leg
Crutch walking:
Remember the phase "step up" when picturing a person going up stairs with crutches.
The good leg goes up first followed by the crutches and the bad leg. The opposite
happens going down the stairs....OR "up to heaven...down to hell"
Delegation:
RNs DO NOT delegate what they can EAT--evaluate, assess, teach
AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
