PNU 120: Exam 1 questions with verified
answers updated to pass
ABCDE Principles - correct answer ✔✔Airway/Cervical Spine: most important step in performing
primary survey. If airway is not established, subsequent steps of the primary survey are futile.
Protect the cervical spine if head or neck trauma is suspected.
Breathing: After achieving a patent airway, assess the presence and effectiveness of breathing
Circulation: After ensuring adequate ventilation, assess circulation
Disability: Perform a quick assessment to determine LOC
Exposure: Perform a quick physical assessment to determine client's exposure to adverse
elements such as heat or cold
Fire Safety: RACE - correct answer ✔✔Rescue anyone in immediate danger
Activate the fire code and notify appropriate person
Confine the fire by closing doors/windows
Evacuate patients and other people to safe area
Oxygen Safety Measures - correct answer ✔✔Place "no smoking" sign on front door of home
(can also be placed by bedroom), inform patient and family dangers of smoking, use cotton
bedding, keep flammable materials away such as nail polish remover, follow general measures
for fire safety
DAME: Falls/Preventing Falls - correct answer ✔✔Drug and alcohol use
Age related physiologic status
Medical problems
Environment
,Interventions to Prevent Falls - correct answer ✔✔- Complete a fall-risk assessment for each
client at admission and at regular intervals. Individualize the plan for each client according to
the results of the fall-risk assessment
- Be sure client knows how to use call light (in reach)
- Use fall-risk alerts such as color-coded wristbands
- Place clients at risk near nurses station
- Keep bed in low position and lock brakes
- Keep side rails up for clients sedated, unconscious, or otherwise compromised
- Nonskid footwear and nonskid bathmats
- Report and document all incidents
Clients in Restraints - correct answer ✔✔- Ask client or guardian to sign consent form
- Assess skin integrity and provide skin care usually every 2 hours
- Pad bony prominences to prevent skin breakdown
- Use a quick-release knot (loose) to bed frame due to raising and lowering the bed
- Loose enough for ROM (2 fingers)
- Remove frequently to ensure good circulation
- Never leave client alone without restraints
- Restraints can be physical or chemical
- Can cause pneumonia, incontinence, and pressure ulcers
- Only 4 hours for adults allowed
- Can use in emergency
Nursing Actions During Seizure - correct answer ✔✔- Stay with client & call for help
- Maintain airway patency & suction PRN
- Administer medications
- Note duration of seizure & type of movements
, - After seizure determine mental status and measure oxygenation saturation and vital signs
Seizure Precautions - correct answer ✔✔- Make sure rescue equipment is at bedside
- Ensure rapid intervention to maintain airway patency
- Inspect client's environment for items that could cause injury during a seizure and remove
items not necessary for current treatment
- Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury
- Advise all caregivers and family to NOT restrain the client during a seizure but to lower him to
the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on side
with feet flexed slightly forward if possible, and loosen clothing
Purposes for Seclusion - correct answer ✔✔- Use for shortest duration necessary and only if less
restrictive measures are not sufficient
- They are for physical protection of the client or other clients or staff
- Must be prescribed in writing, after a face-to-face assessment of the client
Sources of Data Collection & Assessment - correct answer ✔✔1. Primary Sources
- Subjective: Client tells nurse
- Objective: Nurse observes and examines
2. Secondary Sources
- Subjective: What others tell the nurse
- Objective: Data the nurse collects from other sources (family, friends, caregivers, health care
professionals, literature review, and medical records)
Assessment/Data Collection - correct answer ✔✔- Systematic collection of information about
client's present health status to identify needs and additional data to collect based on findings
1. Initial Assessment (baseline data)
2. Focused Assessment
answers updated to pass
ABCDE Principles - correct answer ✔✔Airway/Cervical Spine: most important step in performing
primary survey. If airway is not established, subsequent steps of the primary survey are futile.
Protect the cervical spine if head or neck trauma is suspected.
Breathing: After achieving a patent airway, assess the presence and effectiveness of breathing
Circulation: After ensuring adequate ventilation, assess circulation
Disability: Perform a quick assessment to determine LOC
Exposure: Perform a quick physical assessment to determine client's exposure to adverse
elements such as heat or cold
Fire Safety: RACE - correct answer ✔✔Rescue anyone in immediate danger
Activate the fire code and notify appropriate person
Confine the fire by closing doors/windows
Evacuate patients and other people to safe area
Oxygen Safety Measures - correct answer ✔✔Place "no smoking" sign on front door of home
(can also be placed by bedroom), inform patient and family dangers of smoking, use cotton
bedding, keep flammable materials away such as nail polish remover, follow general measures
for fire safety
DAME: Falls/Preventing Falls - correct answer ✔✔Drug and alcohol use
Age related physiologic status
Medical problems
Environment
,Interventions to Prevent Falls - correct answer ✔✔- Complete a fall-risk assessment for each
client at admission and at regular intervals. Individualize the plan for each client according to
the results of the fall-risk assessment
- Be sure client knows how to use call light (in reach)
- Use fall-risk alerts such as color-coded wristbands
- Place clients at risk near nurses station
- Keep bed in low position and lock brakes
- Keep side rails up for clients sedated, unconscious, or otherwise compromised
- Nonskid footwear and nonskid bathmats
- Report and document all incidents
Clients in Restraints - correct answer ✔✔- Ask client or guardian to sign consent form
- Assess skin integrity and provide skin care usually every 2 hours
- Pad bony prominences to prevent skin breakdown
- Use a quick-release knot (loose) to bed frame due to raising and lowering the bed
- Loose enough for ROM (2 fingers)
- Remove frequently to ensure good circulation
- Never leave client alone without restraints
- Restraints can be physical or chemical
- Can cause pneumonia, incontinence, and pressure ulcers
- Only 4 hours for adults allowed
- Can use in emergency
Nursing Actions During Seizure - correct answer ✔✔- Stay with client & call for help
- Maintain airway patency & suction PRN
- Administer medications
- Note duration of seizure & type of movements
, - After seizure determine mental status and measure oxygenation saturation and vital signs
Seizure Precautions - correct answer ✔✔- Make sure rescue equipment is at bedside
- Ensure rapid intervention to maintain airway patency
- Inspect client's environment for items that could cause injury during a seizure and remove
items not necessary for current treatment
- Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury
- Advise all caregivers and family to NOT restrain the client during a seizure but to lower him to
the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on side
with feet flexed slightly forward if possible, and loosen clothing
Purposes for Seclusion - correct answer ✔✔- Use for shortest duration necessary and only if less
restrictive measures are not sufficient
- They are for physical protection of the client or other clients or staff
- Must be prescribed in writing, after a face-to-face assessment of the client
Sources of Data Collection & Assessment - correct answer ✔✔1. Primary Sources
- Subjective: Client tells nurse
- Objective: Nurse observes and examines
2. Secondary Sources
- Subjective: What others tell the nurse
- Objective: Data the nurse collects from other sources (family, friends, caregivers, health care
professionals, literature review, and medical records)
Assessment/Data Collection - correct answer ✔✔- Systematic collection of information about
client's present health status to identify needs and additional data to collect based on findings
1. Initial Assessment (baseline data)
2. Focused Assessment
