MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
1. 1st priority when a client falls when the nurse is not in the room?: check
on patient for any injuries
2. What do you do when a client is about to about to fall while the nurse is
there?: guide the patient to the floor.
3. Positioning to reduce injury for bony prominences: • Place pillows under
areas and elevate
• Changes position for 2hrs
• Elevate calves to protect heels
4. Reducing shear injury: • Avoid pulling and sliding patient against bed
• Keep head of bed at a slight elevation
• Make sure sheets and blankets have ripples in them that rub against the patient's
skin
• Use others to assist to protect from shearing.
5. Reduce urinary tract infection: Proper cleaning of Perineum (front to back)
6. Preventing Pressure Injuries Positioning: • Pad contact surfaces with foam,
silicone gel, air pads, or other materials with pressure-redistribution properties.
• Do not keep the head of the bed elevated above 30 degrees to prevent shearing.
• Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her.
• When positioning a patient on his or her side, position at a 30-degree tilt.
• Re-position an immobile patient at a frequency consistent with assessed needs.
• Do not place a rubber ring or donut under the patient's sacral area.
• When moving an immobile patient from a bed to another surface, use a desig-
nated slide board well lubricated with talc or use a mechanical lift.
• Place pillows or foam wedges between two bony surfaces.
• Keep the patient's skin directly off plastic surfaces.
• Keep the patient's heels off the bed surface using bed pillow under ankles or a
heel-suspension device.
7. Nutrition: • Ensure a fluid intake between 2000 and 3000 mL/day.
• Help the patient maintain an adequate intake of protein and calories.
8. Skin Care to prevent pressure ulcer: • Perform a daily inspection of the
patient's entire skin
• Document and report any manifestations of skin infection.
• Use moisturizers daily on dry skin and apply when skin is damp
• Keep moisture from prolonged contact with skin:
• Dry areas where two skin surfaces touch, such as the axillae and under the
breasts.
• Place absorbent pads under areas where perspiration collects.
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
• Use moisture barriers on skin areas where wound drainage or incontinence
occurs.
• Do not massage bony prominences.
• Humidify the room.
9. Skin Cleaning (Pressure Ulcer prevention)
• Clean the skin as soon as possible after soiling occurs and at routine
intervals.
• Use a mild, heavily fatted soap or gentle commercial cleanser for inconti-
nence.
• Use tepid rather than hot water.
• In the perineal area, use a disposable cleaning cloth that contains a skin: -
barrier agent.
• While cleaning, use the minimum scrubbing force necessary to remove soil.
• Gently pat rather than rub the skin dry.
• Do not use powders or talc directly on the perineum.
• After cleaning, apply a commercial skin barrier to areas in frequent contact with
urine or feces.
10. Intrinsic contributing factors of pressure ulcers: • Immobilization
• Cognitive deficit
• Chronic illness (eg, diabetes mellitus)
• Poor nutrition
• Steroid use
• Aging
11. Extrinsic Contributing factors to pressure ulcers: • Pressure
• Friction
• Humidity
• Shear force
12. Normal body temperature: 96.4 to 99.5 (depending on the site)
13. Respiration Rate: - 12 to 20 breaths per minute
14. BP: - 120/80 and below; anything higher is abnormal
15. Pulse Ox (saturation): - 94 to 100%
16. Pulse: - 60 to 100 BPM
17. Appropriate measures in taking an oral temperature: • If patiently had food
or a drink wait 20 to 30 min before measuring temp
• Gently place the oral probe (with cover) of the thermometer under the tongue in
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
the posterior sublingual pocket lateral to the center of the lower jaw.
• Leave it in place until the reading is complete.
18. What is the appropriate age range to take oral temperature?: 4 and up
19. Vital signs that can indicate post-surgical pain?: • Elevated Heart Rate
• Breathing rate can be elevated
• Elevated BP
20. Complications of amputations: • Body-image disturbances
• Deep vein thrombosis (DVT)
• Slow wound healing
• Cardiac issues (eg. heart attack)
• Pneumonia
21. Type of pain with amputations?: Possibility of phantom pain
22. Autonomy for a client requiring oral care: • Brush the teeth twice a day.
• Use a soft toothbrush.
• Moisturize oral mucosa and lips every 2 to 4 hours.
• Use chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative
period for patients who undergo cardiac surgery (adult patients).
• Use mouthwash inside the mouth twice a day for adult patients who are on a
ventilator.
• Give the patients the oral supplies
23. Fires: Home fires are the major cause of death and injuries
Older adults & children < 5y/o have the highest risk.
24. Most common causes of fires: Cooking fires
Smoking
Heating Equipment
Home oxygen administration equipment: 75% of home fires involves oxygen,
smoking materials are the ignition source
Remove the client from the area
25. RACE: Rescue - remove patient from danger
Alarm - pull the alarm
Contain - close doors
Extinguish fire (if possible)
26. PASS: Pull the pin
Aim at the base of the fire
Squeeze the handles
Sweep back and forth
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
27. Articulate typical assessment findings for a client with an infection.: •
fatigued
• diaphoretic?
• wrapped in blankets or complaining of feeling chilled
• Are the mucous membranes dry?
• Does the skin have normal elasticity (turgor)?
• pain, redness, swelling, and warmth.
• presence or absence of any rashes
•Presence of breaks or reddened areas of the skin.
• Swollen lymph nodes
• Elevated temperature and pulse rate
28. Infant safety (education for new moms in keeping babies safe): • Don't
Sleep with baby
• Car seat faces backwards for 2 years
• Baby should sleep in their back
• Do not use microwave to heat formula
• Do not sleep with mom and dad
29. Client orientation to a new room may include what specifics?: • Ensure
they can use call light before you leave
• Show them where their personal items are and place them near to them
• Show them where all the furniture is at and walk them around it.
• Also show them where the bathroom is and how to get to it
30. Anytime there is concern over a finding from an unlicensed person
-: assess the patient yourself to confirm the concern
31. Things that can be delegated to unlicensed personnel: Vital signs on a
non-critical patient
Moving/ambulating a patient
Bedside glucose monitoring
Bathing and documenting tasks
32. Benefits of bathing for a client: • Cleans the body
•Stimulates circulation
•Provides relaxation
• Enhance healing.
33. Caring for a patient with dementia/specific nursing interventions: •Pro-
mote patient orientation
• Use simple communication
• Decrease anxiety
1. 1st priority when a client falls when the nurse is not in the room?: check
on patient for any injuries
2. What do you do when a client is about to about to fall while the nurse is
there?: guide the patient to the floor.
3. Positioning to reduce injury for bony prominences: • Place pillows under
areas and elevate
• Changes position for 2hrs
• Elevate calves to protect heels
4. Reducing shear injury: • Avoid pulling and sliding patient against bed
• Keep head of bed at a slight elevation
• Make sure sheets and blankets have ripples in them that rub against the patient's
skin
• Use others to assist to protect from shearing.
5. Reduce urinary tract infection: Proper cleaning of Perineum (front to back)
6. Preventing Pressure Injuries Positioning: • Pad contact surfaces with foam,
silicone gel, air pads, or other materials with pressure-redistribution properties.
• Do not keep the head of the bed elevated above 30 degrees to prevent shearing.
• Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her.
• When positioning a patient on his or her side, position at a 30-degree tilt.
• Re-position an immobile patient at a frequency consistent with assessed needs.
• Do not place a rubber ring or donut under the patient's sacral area.
• When moving an immobile patient from a bed to another surface, use a desig-
nated slide board well lubricated with talc or use a mechanical lift.
• Place pillows or foam wedges between two bony surfaces.
• Keep the patient's skin directly off plastic surfaces.
• Keep the patient's heels off the bed surface using bed pillow under ankles or a
heel-suspension device.
7. Nutrition: • Ensure a fluid intake between 2000 and 3000 mL/day.
• Help the patient maintain an adequate intake of protein and calories.
8. Skin Care to prevent pressure ulcer: • Perform a daily inspection of the
patient's entire skin
• Document and report any manifestations of skin infection.
• Use moisturizers daily on dry skin and apply when skin is damp
• Keep moisture from prolonged contact with skin:
• Dry areas where two skin surfaces touch, such as the axillae and under the
breasts.
• Place absorbent pads under areas where perspiration collects.
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
• Use moisture barriers on skin areas where wound drainage or incontinence
occurs.
• Do not massage bony prominences.
• Humidify the room.
9. Skin Cleaning (Pressure Ulcer prevention)
• Clean the skin as soon as possible after soiling occurs and at routine
intervals.
• Use a mild, heavily fatted soap or gentle commercial cleanser for inconti-
nence.
• Use tepid rather than hot water.
• In the perineal area, use a disposable cleaning cloth that contains a skin: -
barrier agent.
• While cleaning, use the minimum scrubbing force necessary to remove soil.
• Gently pat rather than rub the skin dry.
• Do not use powders or talc directly on the perineum.
• After cleaning, apply a commercial skin barrier to areas in frequent contact with
urine or feces.
10. Intrinsic contributing factors of pressure ulcers: • Immobilization
• Cognitive deficit
• Chronic illness (eg, diabetes mellitus)
• Poor nutrition
• Steroid use
• Aging
11. Extrinsic Contributing factors to pressure ulcers: • Pressure
• Friction
• Humidity
• Shear force
12. Normal body temperature: 96.4 to 99.5 (depending on the site)
13. Respiration Rate: - 12 to 20 breaths per minute
14. BP: - 120/80 and below; anything higher is abnormal
15. Pulse Ox (saturation): - 94 to 100%
16. Pulse: - 60 to 100 BPM
17. Appropriate measures in taking an oral temperature: • If patiently had food
or a drink wait 20 to 30 min before measuring temp
• Gently place the oral probe (with cover) of the thermometer under the tongue in
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
the posterior sublingual pocket lateral to the center of the lower jaw.
• Leave it in place until the reading is complete.
18. What is the appropriate age range to take oral temperature?: 4 and up
19. Vital signs that can indicate post-surgical pain?: • Elevated Heart Rate
• Breathing rate can be elevated
• Elevated BP
20. Complications of amputations: • Body-image disturbances
• Deep vein thrombosis (DVT)
• Slow wound healing
• Cardiac issues (eg. heart attack)
• Pneumonia
21. Type of pain with amputations?: Possibility of phantom pain
22. Autonomy for a client requiring oral care: • Brush the teeth twice a day.
• Use a soft toothbrush.
• Moisturize oral mucosa and lips every 2 to 4 hours.
• Use chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative
period for patients who undergo cardiac surgery (adult patients).
• Use mouthwash inside the mouth twice a day for adult patients who are on a
ventilator.
• Give the patients the oral supplies
23. Fires: Home fires are the major cause of death and injuries
Older adults & children < 5y/o have the highest risk.
24. Most common causes of fires: Cooking fires
Smoking
Heating Equipment
Home oxygen administration equipment: 75% of home fires involves oxygen,
smoking materials are the ignition source
Remove the client from the area
25. RACE: Rescue - remove patient from danger
Alarm - pull the alarm
Contain - close doors
Extinguish fire (if possible)
26. PASS: Pull the pin
Aim at the base of the fire
Squeeze the handles
Sweep back and forth
, MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS
27. Articulate typical assessment findings for a client with an infection.: •
fatigued
• diaphoretic?
• wrapped in blankets or complaining of feeling chilled
• Are the mucous membranes dry?
• Does the skin have normal elasticity (turgor)?
• pain, redness, swelling, and warmth.
• presence or absence of any rashes
•Presence of breaks or reddened areas of the skin.
• Swollen lymph nodes
• Elevated temperature and pulse rate
28. Infant safety (education for new moms in keeping babies safe): • Don't
Sleep with baby
• Car seat faces backwards for 2 years
• Baby should sleep in their back
• Do not use microwave to heat formula
• Do not sleep with mom and dad
29. Client orientation to a new room may include what specifics?: • Ensure
they can use call light before you leave
• Show them where their personal items are and place them near to them
• Show them where all the furniture is at and walk them around it.
• Also show them where the bathroom is and how to get to it
30. Anytime there is concern over a finding from an unlicensed person
-: assess the patient yourself to confirm the concern
31. Things that can be delegated to unlicensed personnel: Vital signs on a
non-critical patient
Moving/ambulating a patient
Bedside glucose monitoring
Bathing and documenting tasks
32. Benefits of bathing for a client: • Cleans the body
•Stimulates circulation
•Provides relaxation
• Enhance healing.
33. Caring for a patient with dementia/specific nursing interventions: •Pro-
mote patient orientation
• Use simple communication
• Decrease anxiety
