ULL Nursing 204 - Exam 2 Questions With Complete Solutions

1. Distraction and music - ANSWER Nonpharmacologic intervention that can reduce pain perception. 2. Patient-controlled analgesia (PCA) - ANSWER Only the patient should press the button to reduce oversedation risk. 3. Preemptive dosing - ANSWER Administering analgesic 30 minutes before activity or sleep to optimize participation and rest. 4. Acute/transient pain - ANSWER Type of pain best described as sudden and short-lived after surgery. 5. Topical heat or cold application - ANSWER Type of cutaneous stimulation for pain control. 6. Anxiety and fear - ANSWER Factors that commonly increase pain perception. 7. Wait ~30 minutes after hot/cold fluids - ANSWER Recommended time to take an oral temperature after a patient has consumed hot tea. 8. Cuff too wide - ANSWER Factor that can cause a falsely low BP reading. 9. Measuring BP and HR supine, sitting, then standing - ANSWER Best method to assess orthostatic hypotension. 10. Factors affecting SpO2 reading - ANSWER Nail polish and cold extremities can affect the reading. 11. Heat stroke skin presentation - ANSWER Hot, dry skin with neurological changes suggests heat stroke rather than heat exhaustion. 12. Factors increasing BP acutely - ANSWER Recent smoking or caffeine typically increases BP acutely. 13. Monitoring diffusion and perfusion - ANSWER The nurse monitors capnography and pulse oximetry. 14. Common cause of inpatient injuries - ANSWER Falls are the most common cause of inpatient injuries. 15. Preventing falls in confused patients - ANSWER Activate bed alarm and keep toilet within reach is the best intervention. 16. Seizure precautions - ANSWER Loosen restrictive clothing and turn to side for a patient with seizure precautions. 17. First action on discovering a fire - ANSWER The first action is to rescue/remove patients in danger. 18. Mode of transmission - ANSWER The method by which an infectious agent is spread from one host to another. 19. Surgical mask - ANSWER A mask worn by patients on airborne precautions during transport to prevent the spread of infectious agents. 20. Sterile field - ANSWER An area free from all microorganisms, established for performing sterile procedures. 21. Contaminated field - ANSWER A sterile field that has been compromised, often by turning one's back on it. 22. Portal of exit - ANSWER The route through which a pathogen leaves its host. 23. Cough etiquette - ANSWER Practices that limit the spread of respiratory secretions, such as covering the mouth/nose when coughing. 24. Health care-associated infection (HAI) - ANSWER An infection that a patient acquires while receiving treatment for another condition within a healthcare setting. 25. Doffing sequence - ANSWER gloves, googles, gown, mask 26. First aid for needlestick - ANSWER The immediate action of washing or cleansing the site of a needlestick injury to reduce exposure. 27. Invasive lines - ANSWER Medical devices that are inserted into the body, increasing the risk of infections. 28. Parenteral nutrition - ANSWER Nutritional support given intravenously, often associated with higher risks of health care-associated infections. 29. Immediate first aid - ANSWER Wash/cleanse the site to reduce exposure. 30. Best intervention for susceptible host - ANSWER Administering influenza vaccination. 31. Nonverbal communication example - ANSWER Facial expression and eye contact. 32. Personal zone of space - ANSWER 18-40 inches. 33. Working phase of a helping relationship - ANSWER Focuses on interventions and achieving goals. 34. Nontherapeutic technique - ANSWER False reassurance. 35. Critical element during handoff - ANSWER Use of standardized format like SBAR. 36. Lateral violence among staff - ANSWER Should be addressed by first acknowledging the behavior. 37. Medication error classification - ANSWER A wrong medication dose given by a nurse is classified as a procedure-related accident. 38. Environmental modification to reduce fall risk - ANSWER Night lights and removing clutter will most reduce fall risk at home for an older adult. 39. Restraint usage protocol - ANSWER Before using restraints, the nurse should first document all alternatives attempted. 40. Standard precautions - ANSWER Apply to all patients to reduce pathogen transmission. 41. SOAP note - ANSWER Contains Subjective, Objective, Assessment, and Plan. 42. Best practice for documentation error - ANSWER Single line through error, initial and date, then correct. 43. Abbreviation to avoid per TJC - ANSWER Avoid using 'U' for unit to prevent ,moso4 44. First step when faxing patient information - ANSWER Verify the recipient and use a cover sheet. 45. Incident report completion - ANSWER Should be completed when a visitor slips in the lobby. 46. Charting by exception (CBE) - ANSWER Focuses on deviations from pre-defined norms. 47. Verbal order in an emergency - ANSWER Write it down, read back to confirm, and enter per policy. 48. Best 'Situation' statement in SBAR - ANSWER States the immediate problem, e.g., 'Mr. Lee's BP is 84/50 and he's dizzy.' 49. Background element in SBAR - ANSWER Includes med allergies and last vital signs. 50. Recommendation - ANSWER Requests specific actions or orders. 51. Assessment - ANSWER The nurse's clinical judgment. 52. Critical item for chest pain SBAR call - ANSWER Exact time pain began and current vitals. 53. Efficiency of SBAR during handoff - ANSWER Focusing on pertinent, concise facts and clear recommendations. 54. PPE for varicella (chickenpox) - ANSWER N95 respirator is required. 55. Removing PPE after droplet precautions - ANSWER Respirator should be removed outside the room. 56. Correct order for DOFFING PPE - ANSWER Gloves → Goggles → Gown → Mask. 57. CLEAN areas of PPE - ANSWER Back of the gown and ties. 58. Introduction in SBAR - ANSWER Establish identity, role, and unit for clarity and safety. 59. Order of SBAR content after introduction - ANSWER Situation → Background → Assessment → Recommendation. 60. First step before donning PPE - ANSWER Perform hand hygiene to reduce contamination before donning PPE. 61. Action after touching face shield with contaminated gloves - ANSWER Change gloves and clean or replace the face shield to prevent cross-contamination. 62. PPE for CONTACT precautions - ANSWER Gloves and gown are required when entering the room. 63. Ineffectiveness of hand sanitizer - ANSWER Hand sanitizer is NOT effective when hands are visibly soiled with blood; soap and water are required. 64. Healthy oral mucosa indication - ANSWER Healthy mucosa is light pink, moist, smooth, and without lesions. 65. Best practice for denture care - ANSWER Keep dentures submerged in water in a labeled cup when not worn to prevent warping/contamination.