NRSG2220 - Exam 3 Questions With Complete Solutions
How do you aid a patient with a shower? Correct Answers
CAN NOT LEAVE PATIENT ALONE EVER
Patient should stay on bench
Warm water = vasodilation risk for dehydration
Check water temp and pressure before getting patient out of bed
Let patient do as much as they can on their own
Once bath is done, dry off floor w towels and give grippy socks
How do you check for hydration status? Correct Answers Skin
turgor
Speed in which it moves back into original place
Tenting = inability to move to original shape after being pinched
Sign of lack of skin elasticity
How do you clean female genitalia? Correct Answers always
proceed from the least contaminated area to the most
contaminated area.
Use clean area of wipe with every wipe
How do you clean male genitalia? Correct Answers retract the
foreskin while washing, then pull back foreskin back over the
penis to prevent constriction (edema or tissue injury may result)
How do you confirm NG tube placemnt? Correct Answers X-
ray
pH
How do you perform a respiratory assessment? Correct
Answers percussion = listen for air in the lungs
,auscultation = clean air moving through lungs
palpation = temp, massess, PMI, extremities, pulse cap refil
How do you perform an integument assessment? Correct
Answers inspection & palpation
Key considerations:
privacy, general survey, infection control
How do you perform general skin care? Correct Answers
Assess skin DAILY and after every episode of incontinence
Cleanse skin when soiled or if asked using no-rinse, pH-
balanced skin cleanser
Avoid soap and overly hot water
Avoid excessive friction and scrubbing
Minimize skin exposure to moisture
How do you use clinical judgement to figure out weather or not
to leave patient in bathroom on their own? Correct Answers
Look out for instability
Off balance
Etc.
Must remain shoulder to shoulder in order to help catch a patient
if at fall risk
Have to always be overcautious as a nursing student and newly
licensed
Always assess and adjust
Ask hospital what the normal protocol in regards to when patient
go to the bathroom
,How is massaging important to a patient? Correct Answers
Goal is to increase circulation to key areas for decrease risk for
skin degradation
Use no scent body lotion
How many grams of fiber should be consumed in a high fiber
diet? Correct Answers 25-30 g (10 per meal)
How many lobes are in each of the lungs? Correct Answers 2
in the left
3 in the right
How much fluid must be in the bladder before the need to urge
occurs? Correct Answers 250mL
How much fluid should a patient with normal urinary
elimination patters void? Correct Answers 30mL
How much water is normal to consume in a day? Correct
Answers 80 oz
50-60% of avg adult total weight
How to measure urine output in patients? Correct Answers 1.
Wear nonsteril gloves when handling containers
2. Wear goggles if you are at risk of splash
3. Ask patient to void into bedan, urinal or specimen container.
4. Put on gloves & pour urine from collection device into
appropriate measuring device. Devices are calibrated in
milliliters
5. Place calibrated container on flat surface for accurate reading,
measure amount of urine and other characteristics
, 6. Discard urine in toilet unless specimen is required
How would you ask a patient about their Aids to elimination ?
Correct Answers Is there anything you do that helps you urinate
How would you ask a patient about their Presence of urinary
diversion ? Correct Answers Tell me about your usual routine
with your ileal conduit
How would you ask a patient about their Present or past
occurrence of voiding difficulties ? Correct Answers Tell me
about any problems you are having now when you urinate
How would you ask a patient about their Recent changes in
urinary elimination ? Correct Answers Have you noticed any
changes in your usual urinary patterns(freq, amount, force,
difficulty, comfort)?
How would you ask a patient about their usual patters of urinary
elimination? Correct Answers How often do you urinate during
the day?
How would you describe your urine?
If any abnormal finding are present in the skin what is the next
step? Correct Answers Alert the nurse and providers of
findings
Perform focused assessment depending on patient history, lab
values, and EMAR
If you hear any abnormal breath sounds, what is important to
documnet? Correct Answers If any of these sounds are heard,
How do you aid a patient with a shower? Correct Answers
CAN NOT LEAVE PATIENT ALONE EVER
Patient should stay on bench
Warm water = vasodilation risk for dehydration
Check water temp and pressure before getting patient out of bed
Let patient do as much as they can on their own
Once bath is done, dry off floor w towels and give grippy socks
How do you check for hydration status? Correct Answers Skin
turgor
Speed in which it moves back into original place
Tenting = inability to move to original shape after being pinched
Sign of lack of skin elasticity
How do you clean female genitalia? Correct Answers always
proceed from the least contaminated area to the most
contaminated area.
Use clean area of wipe with every wipe
How do you clean male genitalia? Correct Answers retract the
foreskin while washing, then pull back foreskin back over the
penis to prevent constriction (edema or tissue injury may result)
How do you confirm NG tube placemnt? Correct Answers X-
ray
pH
How do you perform a respiratory assessment? Correct
Answers percussion = listen for air in the lungs
,auscultation = clean air moving through lungs
palpation = temp, massess, PMI, extremities, pulse cap refil
How do you perform an integument assessment? Correct
Answers inspection & palpation
Key considerations:
privacy, general survey, infection control
How do you perform general skin care? Correct Answers
Assess skin DAILY and after every episode of incontinence
Cleanse skin when soiled or if asked using no-rinse, pH-
balanced skin cleanser
Avoid soap and overly hot water
Avoid excessive friction and scrubbing
Minimize skin exposure to moisture
How do you use clinical judgement to figure out weather or not
to leave patient in bathroom on their own? Correct Answers
Look out for instability
Off balance
Etc.
Must remain shoulder to shoulder in order to help catch a patient
if at fall risk
Have to always be overcautious as a nursing student and newly
licensed
Always assess and adjust
Ask hospital what the normal protocol in regards to when patient
go to the bathroom
,How is massaging important to a patient? Correct Answers
Goal is to increase circulation to key areas for decrease risk for
skin degradation
Use no scent body lotion
How many grams of fiber should be consumed in a high fiber
diet? Correct Answers 25-30 g (10 per meal)
How many lobes are in each of the lungs? Correct Answers 2
in the left
3 in the right
How much fluid must be in the bladder before the need to urge
occurs? Correct Answers 250mL
How much fluid should a patient with normal urinary
elimination patters void? Correct Answers 30mL
How much water is normal to consume in a day? Correct
Answers 80 oz
50-60% of avg adult total weight
How to measure urine output in patients? Correct Answers 1.
Wear nonsteril gloves when handling containers
2. Wear goggles if you are at risk of splash
3. Ask patient to void into bedan, urinal or specimen container.
4. Put on gloves & pour urine from collection device into
appropriate measuring device. Devices are calibrated in
milliliters
5. Place calibrated container on flat surface for accurate reading,
measure amount of urine and other characteristics
, 6. Discard urine in toilet unless specimen is required
How would you ask a patient about their Aids to elimination ?
Correct Answers Is there anything you do that helps you urinate
How would you ask a patient about their Presence of urinary
diversion ? Correct Answers Tell me about your usual routine
with your ileal conduit
How would you ask a patient about their Present or past
occurrence of voiding difficulties ? Correct Answers Tell me
about any problems you are having now when you urinate
How would you ask a patient about their Recent changes in
urinary elimination ? Correct Answers Have you noticed any
changes in your usual urinary patterns(freq, amount, force,
difficulty, comfort)?
How would you ask a patient about their usual patters of urinary
elimination? Correct Answers How often do you urinate during
the day?
How would you describe your urine?
If any abnormal finding are present in the skin what is the next
step? Correct Answers Alert the nurse and providers of
findings
Perform focused assessment depending on patient history, lab
values, and EMAR
If you hear any abnormal breath sounds, what is important to
documnet? Correct Answers If any of these sounds are heard,
