Fundamentals Chapt.20&39

Question 1

Temperature

Answer 1

Room temp should be between 68-74 degrees Fahrenheit(20-23c). Except in critical care units, it’s kept slightly lower to reduce Pt’s metabolic demands

Question 2

Noise control

Answer 2

Avoid long conversations on the phone by going to pts room to talk. Limit conversations in hallways. Encouraging pts to wear headphones while watching tv

Question 3

Safety measures when assisting patients to bed

Answer 3

Make sure the bed wheels are locked and that the bed is in the appropriate position and height for the pt

Question 4

Safety measures making unoccupied beds

Answer 4

1) use good body alignments and wide base of support l
2) ensuring the bed is locked, side rails are lowered and raising bed to appropriate working height will prevent injuries.
3)preform hand hygiene, Donn gloves and practice aseptic techniques

Question 5

Patient teaching post hip surgery

Answer 5

1) fall prevention; use of nonskid bath/shower mats, using night lights, keeping rooms and floor clear of clutter
2) calling for help as needed
3) completing range of motion exercises& the possible use of assistive devices or hip protectors

Question 6

Fall risk; identify at risk patients

Answer 6

1) impaired physical ability
2) altered mental status
3) sensory/ motor deficits

Question 7

Nursing intervention for pts peripheral vascular disease

Answer 7

1)Check the temp of liquids before giving them to a pt.
2)Caution the pt on sleeping on a heating pad or cold pack.
3) use a barrier between pt skin and thermal application

Question 8

What does RACE MEAN?

Answer 8

Rescue any pt in immediate danger
Activate the fire alarm system
Contain the fire by closing doors&window
Extinguish flames or Evacuate

Question 9

Nursing action for suspected poisoning?

Answer 9

1) contact poison control & have the label of the product so you can report :
• the name of the pt, age, amount you believe is involved & any symptoms involved.
• DO NOT induce vomiting unless instructed to do so by poison control

Question 10

Care of an agitated PT?

Answer 10

•try to deescalate the situation by orienting the pt to their surroundings& redirecting.
•encourage family & friends of pt to sit w/them.
• consider speaking to PA about medications such as anti anxiety; restraints are LAST RESORT

Question 11

Patient w/orders for restraints: nurse responsibilities?

Answer 11

•assess skin condition prior to applying the device; if applicable every 15-20 min, check placement of device, positioning & neurovascular status
• apply the device snugly but not so tightly as to interfere with w/blood circulation or nerve function

Question 12

Purpose of deep breathing/ coughing

Answer 12

1) perform a respiratory assessment, monitor lab results, instruct incentive spirometer
2) purpose is to prevent respiratory complications

Question 13

Buck’s traction: purpose

Answer 13

• Velcro boot
•has the advantage of being noninvasive, main purpose to decrease muscle spasms that accompanies fractures

Question 14

Skeletal traction pin sites: expected findings

Answer 14

•a pulling force used to maintain body alignment, fracture alignment, relieve pain and muscle spam
•requieres surgical placement of pins, tongs, screws/wires anchored to the bone
•after healing clear drainage fluid is expected

Question 15

Handling of a fresh plaster cast

Answer 15

• cast must be protected in the drying process to prevent dents and uneven pressure
• use the palm of your hands and flat part of your fingers
• cast edges must be padded

Question 16

Skin appearance after cast removal

Answer 16

•pink, warm, well movement, sensation present

Question 17

Advantage of low air loss mattress

Answer 17

Controls moisture on the skin

Question 18

Continuous passive motion machine

Answer 18

• ordered to restore joint function after ortho surgery to replace joint
• full ROM should be performed
•used to exercise the extremity and joint to prevent contracture muscle, atrophy venous stasis and thrombus( clot ) formation

Question 19

Signs of altered perfusion in pt w/cast

Answer 19

1) cracks
2)edema
3) odor

Question 20

Edema prevention w a leg cast

Answer 20

1) always perform neurovascular assessment with c/o pain
2) report abnormal swelling to the PA
3)try repositioning affected body part and provide elevation

Question 21

Mechanical lift: procedure

Answer 21

•can be used to move a pt from a bed to chair or stretcher& back again
• takes two people to use lift safely

Question 22

Crutches

Answer 22

Used to aid when training to walk following loss of a function