©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
PNU 120: Exam 1 Questions With Correct
Answers
ABCDE Principles - 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 - 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 - 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 - answer✔Drug and alcohol use
Age related physiologic status
Medical problems
Environment
Interventions to Prevent Falls - 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
1|Page
, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
- 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 - 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 - 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 - answer✔- Make sure rescue equipment is at bedside
- Ensure rapid intervention to maintain airway patency
2|Page
11/16/2024 10:16 AM
PNU 120: Exam 1 Questions With Correct
Answers
ABCDE Principles - 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 - 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 - 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 - answer✔Drug and alcohol use
Age related physiologic status
Medical problems
Environment
Interventions to Prevent Falls - 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
1|Page
, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
- 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 - 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 - 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 - answer✔- Make sure rescue equipment is at bedside
- Ensure rapid intervention to maintain airway patency
2|Page
