Exam 1

Question 1

What should be done for feet and nails during basic patient care?

Answer 1

Do not trim nails as it can create wounds. Instead, clean under the nails.

Question 2

How should hair be cared for in basic patient care?

Answer 2

Wash to remove dried blood, oils, dirt, and to get knots out.

Question 3

What is the purpose of oral care in nursing?

Answer 3

To decrease bacteria and promote healthy gums by brushing teeth, cleaning dentures, and using a toothette to swab the mouth.

Question 4

What assistance should be provided for toileting?

Answer 4

Offer a urinal, help on/off the bedpan, and assist to the bathroom.

Question 5

What is important in dressing and grooming?

Answer 5

Provide a new gown.

Question 6

What is the role of active listening in nursing?

Answer 6

Show interest in the patient’s day and pain instead of just performing tasks.

Question 7

Why is rapport important in nursing?

Answer 7

Patients need to trust you; maintain eye contact and appropriate touching.

Question 8

How can comfort measures decrease pain and anxiety?

Answer 8

By using distraction techniques like TV, books, music, guided imagery, and ensuring a restful environment.

Question 9

What are some methods of comfort measures?

Answer 9

Massage, touch, heat for circulation, and cold for swelling and pain relief.

Question 10

What are the bed positions in nursing?

Answer 10

Flat, Low Fowler’s (15-30 degrees), Semi Fowler’s (>30-45 degrees), High Fowler’s (80-90 degrees), Trendelenburg, and Reverse Trendelenburg.

Question 11

What are the benefits of bathing?

Answer 11

Removes microorganisms, stimulates circulation, promotes relaxation, and prevents body odor.

Question 12

What are the levels of bathing?

Answer 12

Self (independent), Partial (with assistance), and Complete (nurse does all).

Question 13

What are the basics of bathing?

Answer 13

Identify the patient, have supplies ready, maintain proper bed height, and document.

Question 14

What safety considerations are there when bathing infants/children?

Answer 14

Ensure supervision, check water temperature, and clean from clean to dirty.

Question 15

What special considerations are there for bathing obese patients?

Answer 15

Ensure safety, assist with cleaning skin folds, and manage moisture effectively.

Question 16

What are the considerations for bathing elderly patients?

Answer 16

Be cautious with dry skin, use lotion while skin is damp, and monitor water temperature.

Question 17

What precautions should be taken when bathing unconscious patients?

Answer 17

Be aware of biting reflex, position carefully, and ensure communication.

Question 18

What are the safety measures for diabetic patients?

Answer 18

Inspect feet daily, clean with mild soap, and wear sturdy shoes.

Question 19

What are the isolation principles for contact precautions?

Answer 19

Wash hands before entering, don gown and gloves, and remove them before exiting.

Question 20

What are the precautions for droplet infections?

Answer 20

Use hand hygiene, gown, gloves, eye protection, and a mask.

Question 21

What are airborne precautions?

Answer 21

Use hand hygiene, gown, N-95 mask, and ensure the patient is in a negative pressure room.

Question 22

What are the normal temperature ranges?

Answer 22

Normal temperature is 36.5-37.5 C or 97.6-99.6 F.

Question 23

What are the normal pulse rates for adults and newborns?

Answer 23

Adult: 60-100 beats/min, Newborn: 130-160 bpm.

Question 24

What are the normal respiration rates for adults and newborns?

Answer 24

Adult: 12-20 breaths/min, Newborn: 40-60 breaths/min.

Question 25

What are the normal blood pressure parameters for adults?

Answer 25

Systolic BP < 120 mmHg and Diastolic BP < 80 mmHg.

Question 26

How is pain defined in nursing?

Answer 26

Pain is what the experiencing person says it is and exists whenever they say it does.

Question 27

What is the normal O2 saturation level?

Answer 27

Normal O2 saturation is above 94%.

Question 28

What are the characteristics of pulse?

Answer 28

Rate, rhythm, and quality (strength).

Question 29

What is a pulse deficit?

Answer 29

The difference between apical and peripheral pulse; normally, both should be equal.

Question 30

What are the phases of Korotkoff sounds?

Answer 30

Phase I: Clear tapping sound (systolic), Phase IV: Muffled sound (diastolic in children), Phase V: Disappearance of sound (diastolic in adults).

Question 31

What are non-pharmacological interventions for pain management?

Answer 31

Heat/cold therapy, massage, position changes, and ensuring a comfortable environment.

Question 32

What are the effects of immobility on the respiratory system?

Answer 32

Decreased activity can lead to atelectasis and hypostatic pneumonia.

Question 33

What cardiovascular complications can arise from immobility?

Answer 33

Orthostatic hypotension, increased workload on the heart, and risk for thrombus.

Question 34

What musculoskeletal complications can arise from immobility?

Answer 34

Osteoporosis, atrophy, contractures, and decubitus ulcers.

Question 35

What are the effects of surgery on the GU system?

Answer 35

Decreased urine output, urinary retention, and the need for monitoring I's and O's.

Question 36

What are the effects of surgery on the GI system?

Answer 36

Ileus, nausea, vomiting, and constipation due to medications.

Question 37

What are the effects of surgery on the respiratory system?

Answer 37

Risk of pulmonary embolism and atelectasis; interventions include encouraging deep breathing.

Question 38

What neurological effects can surgery have?

Answer 38

Changes in level of consciousness and sensation; neuro checks may be required.

Question 39

What cardiovascular effects can surgery have?

Answer 39

Shock due to decreased circulating volume and impaired tissue perfusion.

Question 40

What should be ensured for patients to perform deep breathing exercises?

Answer 40

Pain is under control so they feel comfortable to do deep breathing exercises.

Question 41

What is assessed in a respiratory assessment?

Answer 41

Respiratory assessment.

Question 42

What are the effects of surgery on the neurological system?

Answer 42

LOC varies because of anesthesia but should get back to baseline, sensation, over-sedation.

Question 43

What interventions are needed for neurological checks?

Answer 43

Neuro checks as ordered: Q2 or Q4 to check for A&O, re-orient as often as needed.

Question 44

What are the effects of surgery on the cardiovascular system?

Answer 44

Shock, hemorrhage, DVT.

Question 45

What is shock in the context of surgery?

Answer 45

Body’s response to decrease in circulating volume, impaired tissue perfusion, hypoxia, death.

Question 46

What is hemorrhage and its effect post-surgery?

Answer 46

Not enough volume in the system so tissue perfusion is impaired.

Question 47

What is DVT and its cause?

Answer 47

Occurs in pelvic vein or lower extremities from circulatory system slowing.

Question 48

What interventions are needed for cardiovascular complications?

Answer 48

Fluids, blood transfusion, anticoagulants, CPR and code blue if necessary.

Question 49

What are possible complications after surgery?

Answer 49

Infection, hemorrhage, compartment syndrome, dehiscence, evisceration.

Question 50

What are the signs of infection post-surgery?

Answer 50

May see fever, drainage, pus.

Question 51

What is compartment syndrome?

Answer 51

Severe pain, redness, swelling, pressure, decreased circulation.

Question 52

What are the signs of dehiscence?

Answer 52

Rupture of surgical wounds, edges no longer approximated.

Question 53

What are the risk factors for dehiscence?

Answer 53

Age, obesity, malnutrition, sudden increase in abdominal pressure.

Question 54

What is evisceration?

Answer 54

Internal organs protrude through abdomen, a medical emergency.

Question 55

What is the nursing care for patients in restraints?

Answer 55

Check in on patient 1 hr after the order started, then every 2 hrs.

Question 56

What are examples of restraints?

Answer 56

Wrist, posey, mitt.

Question 57

What are fall risks for patients?

Answer 57

Poor balance, history of fall, pain medications, urgency to go to the bathroom, tethered patients.

Question 58

What are safety concerns with patient mobility?

Answer 58

Body mechanics, positioning, safe transfer techniques, assistive devices.

Question 59

What are the Five Rights of delegation in nursing?

Answer 59

Right task, right circumstance, right person, right direction/communication, right supervision/evaluation.

Question 60

What should not be delegated in nursing?

Answer 60

Evaluation, assessment, teaching, medication, unstable patients.

Question 61

What are the types of surgery?

Answer 61

Inpatient and outpatient.

Question 62

What is inpatient surgery?

Answer 62

Patient may be admitted to hospital unit before surgery, transferred to OR from unit, then to PACU, and back to original unit.

Question 63

What is outpatient surgery?

Answer 63

Patient arrives for surgery, prepped in pre-op area, goes to OR, then to PACU/recovery area, and returns home the same day.

Question 64

What is a major stressor after surgery?

Answer 64

Fearful of pain after surgery; always address it.

Question 65

What interventions are used for pain management after surgery?

Answer 65

Pain medication, comfort measures, antiemetics.

Question 66

What comfort measures can be used post-surgery?

Answer 66

Reposition, elevate, splint incision, hold pillow against incision when coughing or sneezing, ice/heat, massage.

Question 67

What is important for discharge care of a patient?

Answer 67

Signs and symptoms of infection, activity level, diet, pain medication, use of braces, lifting limitations, driving restrictions, care of drains, follow-up appointments.