Contractures, DVT, Constipation, Decreased cardiac output, Pneumonia, and pressure ulcers are

some complications of immobility

The nurse notices that the new nurse needs further teaching when she stated that

a prophylactic antibiotic is given any time prior incision

The nurse notices that the patient is at risk for falls because the patient

has changes in vision, like diabetic retinopathy

The nurse recognized that the new nurse understands about cane when she tells the client

the cane should be the height of his wrist while standing

The nurse noticed that the new nurse need further education when she

did not lock the brakes to secure the wheelchair

Unstageable pressure ulcer is identified mostly because

the base is covered with eschar, wound bed is not visible

The nurse is educating the new nurse about Stage 3 pressure ulcers she tells her that

the bone, tendon, and muscles are not exposed

The nurse recognizes that the new nurse understands the transfer technique because she placed

the chair at the angle to the bed on the pt's strong side

The nurse is ready to administer Morphine for Pre-op medications, the nurse knows to

administer the prescribed pre-op medication in correct dose

The nurse educates her client about ambulatory aids. She educates the pt. ambulatory aids are

walker (with or without rollers), hemi-cane, straight cane,

The nurse notices the new nurse need further teaching when she assessed a client for pain and

stated that the patient is lying about his pain level of 5

The nurse recognized the clients lab values showed a sign of nutrition inadequate when

his albumin <3.5 g /dL and prealbumin was < 19.5 mg/dL

Hydrocolloids and hydrogels are examples of Autolytic wound debridement. This process uses

the body's own healing process to remove dead tissue

The client ask the nurse to further explain the use of biological wound debridement

the nurse states that its the use maggots on necrotic tissue

Review the pt's chart to ensure all documentation, pre-op procedures, and orders are completed

this is known as a Pre-Op chart review

The nurse notices that the client understands how to maintain his skin integrity when he

raises up from the wheelchair for 10 seconds every hour

The nurse notices that the new nurse understands about informed consent when she

stated that the nurse verify the consent form is signed

The nurse notices that the client needs further attention when he states when he use his walker

he takes big enough steps while resting on the walker

The nurse examining a patient pressure ulcer notices that the muscle is exposed. Slough present

the nurse notices this as a Stage 4 pressure ulcer

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NUR 242 Exam 1

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Med Surge Nursing Concepts Unit 1-3 Galen College of Nursing

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Questions 27

Answers

1
Contractures, DVT, Constipation, Decreased cardiac output, Pneumonia, and pressure ulcers are
things nurses should look for in mobile patients
complications for only elderly patients
some complications of immobility
causes of urinary tract infection
2
The nurse notices that the new nurse needs further teaching when she stated that
removal of catheter by day 2 counting day of surgery as 0
the patient should have his beta blocker prior to surgery
a prophylactic antibiotic is given any time prior incision
a prophylactic antibiotic is given 1 hour prior to incision
3
Skin is intact, usually over bony prominence area. It is red and does not blanch
Stage 1 pressure ulcers
Stage 3 pressure ulcers
Stage 4 pressure ulcers
Stage 2 pressure ulcers
4
The nurse notices that the patient is at risk for falls because the patient
has changes in vision, like diabetic retinopathy
is a 23 yo hospitalized for broken arm
ambulates with steady gait without assistance
stated that they do not like the food
5
Wound debridement that is the removal of dead tissue using a surgical procedure is known as
Enzymatic
Autolytic
Surgical
Biological
6
Enzymatic wound debridement that uses chemical enzymes to remove dead tissue can be
Calcium Alginate
Santyl Ointment
Silver nitrate dressings
Med Honey
7
The nurse recognized that the new nurse understands about cane when she tells the client
the cane should be the height of his wrist while standing
the cane should be at waist height to avoid stretching
that his weak hand should be on the cane
to move the cane and his stronger leg forward together
8
The nurse noticed that the new nurse need further education when she
put the bed at waist level when providing direct care
did not lock the brakes to secure the wheelchair
maintained a wide, stable base at her feet to transfer pt
kept the pt directly in front of her
9
Unstageable pressure ulcer is identified mostly because
the base is covered with eschar, wound bed is not visible
skin is intact and its the color of purple/maroon
the base is covered with slough, wound bed is still visible
muscle is exposed and the wound of the bed is visible
10
Impaired mobility, chronic diseases, peripheral neuropathy, and arthritis are all
Signs of presyopia
Risk for falls
Risk for infection
Things to look for in elderly patients
11
The nurse is educating the new nurse about Stage 3 pressure ulcers she tells her that
you are not able to see the wound bed
the bone is partially exposed
the bone, tendon, and muscles are not exposed
the damage does not extends down to the fascia
12
The nurse recognizes that the new nurse understands the transfer technique because she placed
the chair at the angle to the bed on the pt's weaker side
the chair at the bottom of the bed and brought her forward
the chair at the angle to the bed on the pt's strong side
the chair 2 feet away from the bed to help with space
13
The nurse is ready to administer Morphine for Pre-op medications, the nurse knows to
raise siderails, and place bed in high position
place call light within reach and lower siderails
administer the prescribed pre-op medication in correct dose
properly identify patient by asking family member pt name
14
The nurse educates her client about ambulatory aids. She educates the pt. ambulatory aids are
wheelchair or medical staff assistance
walker (with or without rollers), hemi-cane, straight cane,
the medical staff assisting at the weaker side
stretcher or straight cane
15
The nurse notices the new nurse need further teaching when she assessed a client for pain and
used the 0-10 pain scale as an assessment tool
referred the patient to pain management for chronic pain
stated that pain is the 5th vital sign
stated that the patient is lying about his pain level of 5
16
The nurse recognized the clients lab values showed a sign of nutrition inadequate when
his albumin >3.5 g/dL and prealbumin was < 19.5 mg/dL
his albumin <3.5 g /dL and prealbumin was < 19.5 mg/dL
his prealbumin was >19.5 mg/dL
his albumin >3.5 g/dL
17
Hydrocolloids and hydrogels are examples of Autolytic wound debridement. This process uses
uses tap water and the air to help with the healing
dextrose water to clean wound daily and apply TAO
the body's own healing process to remove dead tissue
uses chemical enzymes to remove dead tissue
18
Wet-to-dry wound debridement. Alginate, silver dressings, and mesalt are examples of
Surgical
Autolytic
Mechanical
Enzymatic
19
The client ask the nurse to further explain the use of biological wound debridement
the nurse states that its left open for the air to help heal
the nurse states that its the use maggots on necrotic tissue
the nurse states that during surgery the Dr. uses alginate
the nurse explains the wet-to-dry method
20
Skin is not intact; superficial; open or fluid filled blister, or shallow crater are known as
deep tissue injury
Unstageable pressure ulcers
Stage 1 pressure ulcers
Stage 2 pressure ulcers
21
Review the pt's chart to ensure all documentation, pre-op procedures, and orders are completed
this is known as a Pre-Op chart review
needs to be done prior to anesthesia is given
after the surgery is completed
this is when you check for sickle cell history
22
The nurse notices that the client understands how to maintain his skin integrity when he
stated that he would only be repositioned when he request it
raises up from the wheelchair for 10 seconds every hour
refused to be repositioned for over 4 hours while sleeping
refused to remove his shoes and sock to check for open areas
23
The nurse notices that the new nurse understands about informed consent when she
explained the surgery to a pt who did not understand
stated that the surgeon signs it before or after sedation
stated that a blind patient gives a verbal consent
stated that the nurse verify the consent form is signed
24
With general anesthesia a respiration <10 breaths a min, may indicate respiratory depression
due to anesthetic or opioids
and is common with local anesthesia
and is a normal reaction after surgery
and is not a concern until respiratory breaths is <8
25
Used often in surgery of head, neck, upper torso, and abdomen. Once in PACU asses airway
Regional anesthesia
General Anesthesia and Regional anesthesia
Lidocaine
General Anesthesia
26
The nurse notices that the client needs further attention when he states when he use his walker
make sure the walker is set down on all legs before moving
he takes big enough steps while resting on the walker
he lift the walker and move it about 2 feet forward
check his balance before lifting walker again
27
The nurse examining a patient pressure ulcer notices that the muscle is exposed. Slough present
the nurse notice the tunneling as unstageable pressure ulcer
the nurse documents this as a Stage 5 pressure ulcer
the nurse notices this as a Stage 4 pressure ulcer
the nurse turn patient on side and call provider ASAP

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