MDC 1 Exam 2 NUR 2356 Study Test Final Exam Questions and Answers (Latest ).pdf

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1. AppropriateSnursingSactions:SNicole



a) WhenSaSclientSfalls

• 1stSpriorityS–

check on patient for any injuries befor
S S S S S S S



e that, guide the patient to the floor.
S S S S S S S




b) PositioningStoSreduceSinjurySforSbonySprominences

• PlaceSpillowsSunderSareasSandSelevate

• ChangesSpositionSforS2hrsS

Elevate calves to protect h
S S S S



eels


c) ReducingSshearSinjuryS(medSsurgSpgS447)

• AvoidSpullingSandSslidingSpatientSagainstSbed

• KeepSheadSofSbedSatSaSslightSelevation

• MakeSsureSsheetsSandSblanketsShaveSripplesSinSthemSthatSrubSagainstSth

e patient’sskin
S S




• UseSothersStoSassistStoSprotectSfromSshearing.

d) ReduceSurinaryStractSinfection

• ProperScleaningSofSPerineumS–SfrontStoSback


e) ReducingSpressureSulcers-SfactorsSthatSareScontributorsS(medSsurgSpgS448)



Preventing Pressure Injuries Positioning
S S S




• PadScontactSsurfacesSwithSfoam,SsiliconeSgel,SairSpads,SorSotherSmaterialsSwit

CHAMBERLAIN COLLEGE OF NURSING NUR 2356 FINAL S S S S S S S



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h pressure-redistribution properties.
S S S



• S Do not keep the head of the bed elevated above 30 degrees to prevent shearing.
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• UseSaSliftSsheetStoSmoveSaSpatientSinStheSbed.SAvoidSdraggingSorSslidingShimSorShe

r.
• WhenSpositioningSaSpatientSonShisSorSherSside,SpositionSatSaS30-degreeStilt.

• Re-positionSanSimmobileSpatientSatSaSfrequencySconsistentSwithSassessedSneeds.

• S Do not place a rubber ring or donut under the patient's sacral area.
S S S S S S S S S S S S




• S When moving an immobile patient from a bed to another surface, use a desig
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nated slideboard well lubricated with talc or use a mechanical lift.
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• S Place pillows or foam wedges between two bony surfaces.
S S S S S S S S



• S Keep the patient's skin directly off plastic surfaces.
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• KeepStheSpatient'sSheelsSoffStheSbedSsurfaceSusingSbedSpillowSunderSankle

s or a heel-suspension device.
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Nutrition
• EnsureSaSfluidSintakeSbetweenS2000SandS3000SmL/day.

• S Help the patient maintain an adequate intake of protein and calories.
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Skin Care S




• PerformSaSdailySinspectionSofStheSpatient'sSentireSskin




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• DocumentSandSreportSanySmanifestationsSofSskinSinfection.

• UseSmoisturizersSdailySonSdrySskinSandSapplySwhenSskinSisSdamp

• KeepSmoistureSfromSprolongedScontactSwithSskin:

• DrySareasSwhereStwoSskinSsurfacesStouch,SsuchSasStheSaxillaeSandSunderStheSbreas

ts.
• S Place absorbent pads under areas where perspiration collects.
S S S S S S S



• UseSmoistureSbarriersSonSskinSareasSwhereSwoundSdrainageSorSincontinenceSocc

urs.
• DoSnotSmassageSbonySprominences.

• HumidifyStheSroom.

Skin Cleaning
S



• CleanStheSskinSasSsoonSasSpossibleSafterSsoilingSoccursSandSatSroutineSintervals.

• UseSaSmild,SheavilySfattedSsoapSorSgentleScommercialScleanserSforSincontinence.

• UseStepidSratherSthanShotSwater.

• InStheSperinealSarea,SuseSaSdisposableScleaningSclothSthatScontainsSaSskin-

barrier agent. S



• WhileScleaning,SuseStheSminimumSscrubbingSforceSnecessaryStoSremoveSsoil.

• GentlySpatSratherSthanSrubStheSskinSdry.

• DoSnotSuseSpowdersSorStalcSdirectlySonStheSperineum.

• AfterScleaning,SapplySaScommercialSskinSbarrierStoSareasSinSfrequentScontactSw

ith urine orfeces.
S S S




f) ForSvitalSsignsSoutSofSrangeS(i.eSlowSoxygenSsaturation)S(moduleS1SslideS56-

59)
• NormalSbodyStemperatureS96.4StoS99.5S(dependingSonStheSsite)

• RespirationSRateS–S12Sto20SbreathsSperSminute


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• BPS–S120/80SandSbelow;SanythingShigherSisSabnormal

• Pulse-OximetryS(saturation)S–S94StoS100%

• PulseS–S60StoS100SBPM

g) AppropriateSmeasuresSinStakingSanSoralStemperatureS(moduleS1Sslides55)




h) VitalSsignsSthatScanSindicateSpost-surgicalSpain?




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S S S S S S S



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