Final exam

Question 1

Define Abduction, Adduction, Flexion, Extension

Answer 1

Abduction: away from body
Adduction: towards the body
Flexion: contract
Extension: straigten

Question 2

Who does the work in passive ROM and active ROM

Answer 2

Patient= active
nurse= passive

Question 3

COAL: What side does the cane go one.

Answer 3

Cane Opposite Affected Leg
Cane goes on strong side

Question 4

What foot do you step with when using a Walker

Answer 4

Wandering Willa’s Always Late
Walk With Affected Leg

Question 5

Prone Position

Answer 5

face down ass up

Question 6

Supine

Answer 6

Supine you’re on your spine
laying flat on your back, face up

Question 7

Sims

Answer 7

Laying on side with your legs separated

Question 8

Lateral

Answer 8

laying on side with legs together

Question 9

Fowlers: high and semi

Answer 9

Semi: 45 HOB, up right position
High: 90 HOB up right position

Question 10

Sterile Field Rules

Answer 10

1” margin, is unsterile
Sterile touches sterile

Question 11

What safety measures are needed when getting a patient up to walk to the bathroom

Answer 11

Lower bed, non skid socks, gait belt

Question 12

What is the process of log rolling? Who is it used for

Answer 12

Grab chuk under patient and roll to side, careful of head making sure it is being moved at the same time.
Used when patients have head or spine injury

Question 13

Normal hourly urine output is?

Answer 13

40 mL

Question 14

What interventions can the nurse implement to prevent constipation?

Answer 14

Ability, hydration, high fiber diet, proper positioning, privacy

Question 15

What is normal infant vital signs ranges

Answer 15

T: same as adult (100 is fever)
R: 20-30
P: 80-140
BP: 70-100/ 60
O2: 90% >

Question 16

if a bp cuff is too big, what does it do to the reading

Answer 16

increases blood pressure

Question 17

skin breakdown can occur in as little as ___ hours

Answer 17

2

Question 18

what 2 factors lead to skin breakdown

Answer 18

fiction and shear
moisture
pressure

Question 19

what are the 5 p’s

Answer 19

pain
position
potty
pathways
personal belongings

Question 20

How many tiers of isolation are there? What are they?

Answer 20

1: standard precautions
2: transmission based

Question 21

What Braden score indicates risk for skin breakdown?

Answer 21

<9

Question 22

Does a high number or a low number indicate a fall risk on the Morse Fall Tool?

Answer 22

high

Question 23

Name 4 interventions to prevent a patient from falling

Answer 23

non- skid socks, lowering bed, bed rails, fall risk bracelet, gait belt, walker, bed alarm

Question 24

Name 3 never events

Answer 24

falls, distribution of wrong blood, foreign objects in body

Question 25

How do you wash the eyes

Answer 25

inner to outer

Question 26

1 tsp= ? mL

Answer 26

5

Question 27

10 kg= ? lb

Answer 27

22

Question 28

1 oz. = ? ml

Answer 28

30

Question 29

1 gm= ? mg

Answer 29

1,000

Question 30

54 g= ? kg

Answer 30

0.054

Question 31

1.8 mg= ? mcg

Answer 31

1,800

Question 32

5 L= ? ml

Answer 32

5,000

Question 33

510 mg= ? g

Answer 33

0.510

Question 34

1 tbsp= ? ml

Answer 34

15

Question 35

1 tbsp= ? tsp

Answer 35

3

Question 36

What are the 3 transmission based precautions?

Answer 36

1. contact: gloves and gown 2. Droplet: mask, gloves, glown 3. airborne: full PPE

Question 37

What are some things to consider with Neutropenic Precautions?

Answer 37

no fresh flowers, no food that come from outside, or could have possible diseases, leave door closed.

Question 38

When is range of motion best performed?

Answer 38

with hygiene activities (ex. during a bed bath)

Question 39

With a cane what side should it be held on, and what foot should be stepped first?

Answer 39

Held on strong side Cane, strong foot, weak foot

Question 40

With a walker, what should be the steps when walked

Answer 40

walker and weak leg first followed by strong leg

Question 41

What are the point of crutches?

Answer 41

to assist with eliminating weight bearing on the legs.

Question 42

What are some good body mechanics?

Answer 42

bed working height wide base of support squat to lift push vs. lift get help

Question 43

factors that affect mobility and activity

Answer 43

lifespan nutrition lifestyle stress disease

Question 44

Define transfer definitions: Atrophy hypertrophy Flaccidity Spasticity Tremor Paresis Paresthesia

Answer 44

Atrophy: wasting muscle away hypertrophy: enlargement Flaccidity: soft or limb Spasticity: abnormal increase in muscle tone Tremor: shakes Paresis: partial paralysis Paresthesia: numbness or tingling

Question 45

Safety interventions for fall risk patients: equipment and actions

Answer 45

Equipment: low bed, floor mats, fall risk bracelet, slippers, gait belt, bed alarm Actions: orientate patient, reduce clutter, toileting schedule, hourly checks

Question 46

What are every time actions when collecting specimen?

Answer 46

label clearly utilize gloves and hand hygiene utilize appropriate containers transport in a specimen transport bag be aware of the timing

Question 47

Do you need a full stool for stool specimen collection?

Answer 47

no, just grab a little Also, use a toilet hat to collect patients stool.

Question 48

Things to know for a clean catch/midstream urine specimen

Answer 48

must use specific wiping packets before use (each wipe= 1 cloth) (females each side of labia front to back, then down the middle) begin voiding, without stopping the stream insert the container and collect a sample, finish voiding

Question 49

Things to remember with foley UA

Answer 49

alcohol swab the specimen port before clamp catheter tubing for 20-30 minutes use sterile syringe 10-20 ml of urine clean up with alcohol wipe again and UNCLAMP the catheter

Question 50

Timed urine samples

Answer 50

Specimen containers are refrigerated during collection in the soiled utility room refrigerator if you miss any output, the collection and time must be restarted