Exam 3: NUR209/ NUR 209 (New 2024/ 2025 Terms in this set (321)
Update) Medical Surgical Nursing II | Questions
Original
and Verified Answers| 100% Correct| A Grade
– Fortis sites to assess pulses
temporal
carotid
apical
brachial
radial
femoral
popliteal
pedal
posterior tibia
Practice questions for this set
Learn
1/7
Study using Learn
1. Location and radiation
2. Character or quality
3. Quantity or severity
4. Timing
5. Setting
6. Aggravating or relieving factors
7. Associated factors
8. Patients perception location of apical pulse
Select the correct term locate fifth intercostal space at the left
midclavicular line.
1
What is tachypnea?
What is tachypnea?
rapid breathing (>20 breaths/ min)
2
bradypnea
eight critical characteristics
slow breathing (<12 breaths/min)
3
what is apnea?
normal vital signs
absence of breathing (> or = 10 secs)
4
normal breathing
cachectic appearance
eupnea
Don't know?
3 multiple choice options
,difficulty breathing nursing interventions for musculoskeletal
impairment
dyspnea
1. positioning: prone, side-lying, supine, sims,
3 multiple choice options
fowlers, dorsal recumbent, Trendelenburg's
what is Biot? 2. turning schedules (every 2hr)
3. logrolling
cyclic breathing pattern characterized by 4. ROM exercises
shallow breathing alternating with periods of
apnea 3 multiple choice options
Cheyne-Stokes respirations important measure for patient safety with a
musculoskeletal deficit
cyclic breathing pattern characterized by
periods of respirations of increased rate and - physical therapy
depth alternating with periods of apnea - using proper body mechanics when lifting
- providing a safe environment
3 multiple choice options - using assistive devices
Kussmaul respirations 3 multiple choice options
increased rate (above 20 beats/min) and depth t physiologic impact does immobility have
of respirations
1. muscle atrophy and weakness
3 multiple choice options 2. contractures and joint pain
atelectasis (alveoli collapse) and pneumonia 3. increased cardiac workload
prevention 4. orthostatic Hypotension
5. thrombus formation and embolism
deep breathing and incentive spirometer are 6. decreased lung expansion
beneficial in maximizing air exchange
psychological impact immobility have on a
manifestations of altered mobility patient
-decreased muscle strength and tone sensory deprivation
-lack of coordination confusion
-altered gait hallucinations
-falls pain
-decreased joint flexibility anxiety
-pain on movement anger
3 multiple choice options depression
powerlessness
functions of the musculoskeletal
care for a patient who just had hip replacement
alignment and posture surgery
balance
coordinated movement 1. Prevent adduction of the affected hip and leg
2. Use abductor pillows
3 multiple choice options 3. Avoid hip flexion <90 degrees
3 multiple choice options
, how can nurses prevent musculoskeletal injury - To be comatose, you need a response of 8 or
less.
1. Use the large muscle groups of the legs.
2. Work at the appropriate height for body factors are included in the Hendrich II Fall Risk
position. Model
3. Use mechanical lifts or assistance when
- Age and gender
possible.
-Medication use
what are national patient safety goals? -Cognitive status
-History of falls
-identify patients correctly
-improve staff communication
5 or greater = high risk
-use medicine safely
-use alarms safely 3 multiple choice options
-prevent infection
Braden Scale is used for
-identify patient safety risks
-prevent mistakes in surgery Pressure ulcer risk assessment
common manifestations of altered safety
16 or less (suggests risk for developing pressure
- motor vehicle incidents ulcer)
- falls
What does the Braden looks at
- poisoning
- suffocation and drowning sensory perception
- fires moisture
activity
Mini-Mental State Examination
mobility
- Brief screening test for cognitive dysfunction nutrition
Includes screening items for orientation, friction
registration, attention and calculation, recall and shear
language
difference between huddles and debriefing
- Max score is 30
- Severe cognitive impairment = 15 or less Huddles are held at the beginning of a shift to
highlight important issues that need attention
Morse Fall Scale
while
A rapid and simple method of assessing a
debriefing is used after an event to explore
patient's likelihood of falling.
what went well or could have been done better
45 points or higher= high risk 3 multiple choice options
25-44 points = moderate risk
0-24= low risk restraints
Glasgow Coma Scale Prevent patient from pulling out tubes that
could cause harm; manage violent behavior that
-an assessment they do to look at level of jeopardizes immediate physical safety of
consciousness. patient, staff
3 multiple choice options
Update) Medical Surgical Nursing II | Questions
Original
and Verified Answers| 100% Correct| A Grade
– Fortis sites to assess pulses
temporal
carotid
apical
brachial
radial
femoral
popliteal
pedal
posterior tibia
Practice questions for this set
Learn
1/7
Study using Learn
1. Location and radiation
2. Character or quality
3. Quantity or severity
4. Timing
5. Setting
6. Aggravating or relieving factors
7. Associated factors
8. Patients perception location of apical pulse
Select the correct term locate fifth intercostal space at the left
midclavicular line.
1
What is tachypnea?
What is tachypnea?
rapid breathing (>20 breaths/ min)
2
bradypnea
eight critical characteristics
slow breathing (<12 breaths/min)
3
what is apnea?
normal vital signs
absence of breathing (> or = 10 secs)
4
normal breathing
cachectic appearance
eupnea
Don't know?
3 multiple choice options
,difficulty breathing nursing interventions for musculoskeletal
impairment
dyspnea
1. positioning: prone, side-lying, supine, sims,
3 multiple choice options
fowlers, dorsal recumbent, Trendelenburg's
what is Biot? 2. turning schedules (every 2hr)
3. logrolling
cyclic breathing pattern characterized by 4. ROM exercises
shallow breathing alternating with periods of
apnea 3 multiple choice options
Cheyne-Stokes respirations important measure for patient safety with a
musculoskeletal deficit
cyclic breathing pattern characterized by
periods of respirations of increased rate and - physical therapy
depth alternating with periods of apnea - using proper body mechanics when lifting
- providing a safe environment
3 multiple choice options - using assistive devices
Kussmaul respirations 3 multiple choice options
increased rate (above 20 beats/min) and depth t physiologic impact does immobility have
of respirations
1. muscle atrophy and weakness
3 multiple choice options 2. contractures and joint pain
atelectasis (alveoli collapse) and pneumonia 3. increased cardiac workload
prevention 4. orthostatic Hypotension
5. thrombus formation and embolism
deep breathing and incentive spirometer are 6. decreased lung expansion
beneficial in maximizing air exchange
psychological impact immobility have on a
manifestations of altered mobility patient
-decreased muscle strength and tone sensory deprivation
-lack of coordination confusion
-altered gait hallucinations
-falls pain
-decreased joint flexibility anxiety
-pain on movement anger
3 multiple choice options depression
powerlessness
functions of the musculoskeletal
care for a patient who just had hip replacement
alignment and posture surgery
balance
coordinated movement 1. Prevent adduction of the affected hip and leg
2. Use abductor pillows
3 multiple choice options 3. Avoid hip flexion <90 degrees
3 multiple choice options
, how can nurses prevent musculoskeletal injury - To be comatose, you need a response of 8 or
less.
1. Use the large muscle groups of the legs.
2. Work at the appropriate height for body factors are included in the Hendrich II Fall Risk
position. Model
3. Use mechanical lifts or assistance when
- Age and gender
possible.
-Medication use
what are national patient safety goals? -Cognitive status
-History of falls
-identify patients correctly
-improve staff communication
5 or greater = high risk
-use medicine safely
-use alarms safely 3 multiple choice options
-prevent infection
Braden Scale is used for
-identify patient safety risks
-prevent mistakes in surgery Pressure ulcer risk assessment
common manifestations of altered safety
16 or less (suggests risk for developing pressure
- motor vehicle incidents ulcer)
- falls
What does the Braden looks at
- poisoning
- suffocation and drowning sensory perception
- fires moisture
activity
Mini-Mental State Examination
mobility
- Brief screening test for cognitive dysfunction nutrition
Includes screening items for orientation, friction
registration, attention and calculation, recall and shear
language
difference between huddles and debriefing
- Max score is 30
- Severe cognitive impairment = 15 or less Huddles are held at the beginning of a shift to
highlight important issues that need attention
Morse Fall Scale
while
A rapid and simple method of assessing a
debriefing is used after an event to explore
patient's likelihood of falling.
what went well or could have been done better
45 points or higher= high risk 3 multiple choice options
25-44 points = moderate risk
0-24= low risk restraints
Glasgow Coma Scale Prevent patient from pulling out tubes that
could cause harm; manage violent behavior that
-an assessment they do to look at level of jeopardizes immediate physical safety of
consciousness. patient, staff
3 multiple choice options
