L2

Question 1

Standing posture
( head, chest, abdominal, feet)

Answer 1

Head erect
Chest slightly raised
Abdominal is comfily tucked
Feet placed apart

Question 2

Proper sitting
Head, back, body-weight, feet)

Answer 2

Head erect
Back straight
Body weight evenly distributed
Both feet are supported to ground

Question 3

Prevent injury at work

Answer 3

Good body posture

Enhance balance

Good body movement coordination

Question 4

Type of patient position on bed

Answer 4

Supine position
Prone position
Lateral position
Recovery position
Fowlers position (high, semi)

Question 5

Supine position good?

Answer 5

Promote rest and healing
For post-surgery after aneasthetic

Question 6

Prone position any good?

pillow to knee, head aside

Answer 6

Promote drainage of mouth and throat
Alternative position for pressure injury

Question 7

Lateral position

Lower head
Pillow behind the back and between legs

Answer 7

Promote proper back alignment
Relieve pressure on scapula, sacrum and heels

Question 8

Recovery position

Answer 8

Promote drainage of mouth for unconscious patient

Head to one side, raise left arm, rest the right arm

Flex hip and knee, separate patient’s leg

Question 9

Fowlers position

Answer 9

For activity
Relieve pressure on diaphragm
30-45 normal
60-90 high fowler

Question 10

Lithotomy position

Answer 10

Provide maximum exposure of female genitalia
Use for rectal urologic procedures
Maintain privacy

Question 11

Trendelenburg position

Answer 11

Leg up head down
Improve blood flow to brain

Question 12

Reverse trendelenburgs

Answer 12

Head up leg down

Question 13

Common risk of fall

Answer 13

Increasing of age
Hip weakness
Cognitive impair
Arthritis
Diabetes
Postural hypotension

Question 14

Morse fall scale

Answer 14

History of fall
Ambulatory aid
IV therapy?
Gait
Mental status

Question 15

Fall prevention

Answer 15

1. Dry floor and clear walkway
2. Adjust bed to low level and raise bedside rail
3. Wear appropriate size of clothing
4. Appropriate walking aids
5. Place call bell within reach
6. Advice avoiding sudden change of position

Question 16

Fall prevention for nurse

Answer 16

1. Allocate bed near nurse
2. Place “high fall risk” sign over bed head
3. Apply anti-fall device such as safety straps
4. Provide fall prevention education to patient
5. Apply physical restrain

Question 17

What to do after fall

Answer 17

1. Call for help
2. Vital sign and conscious test
3. Comfort patient
4. Head to toe assessment to identify injury
5. Dont move patient until safe
6. Report to incharge
7. Record fall incident

Question 18

Physical restrains

Answer 18

Safety vest
Safety belt
Restrain gloves
Magnetic restraints

Question 19

Chemical restrains

Answer 19

Sedatives
Psychotropic drugs

Question 20

Purpose of restrain

Answer 20

1. Reduce risk of fall to patient who is highly susceptible to fall out of bed
2. Prevent patient from injuring-self
3. Prevent disruption of therapy

Question 21

Potential harm of using restrain

Answer 21

Respiratory difficulties
Impaired circulation
Skin breakdown
Incontinence
Anxiety
Depression

Question 22

Principles of using restraints

Answer 22

1. Apply only when it is absolutely necessary
2. Apply for the shortest period of time
3. Do not apply restraint out of staff convenience or patient punishment
4. Restraint should be prescribed and renew by doctor

Question 23

Factors of pressure ulcer

Answer 23

Exterior pressure
Friction and shearing force
Temperature and moist skin

Question 24

External pressure

Answer 24

Supine position
Occipital bone, scapula, vertebra, sacrum, coccyx, calcaneus

Prone position:
Frontal bone, mandible, humerus, sternum, pelvis, patella, tibia

Lateral position:
Scapula, ribs, iliac crest, femur, lateral knee, lateral malleolus, medial melleolus

Question 25

Risk of pressure ulcer development

Answer 25

Immobility Nutrition/ hydration Mental status Age

Question 26

Development of pressure ulcer

Answer 26

Stage1: non-blanchable erythema of intact skin Stage2: partial thickness skin loss with exposed dermis Stage3: full thickness skin loss with exposed dermis Stage4: full thickness skin loss with sinus tract

Question 27

Prevent pressure ulcer

Answer 27

Pressure relieving device (Gel pad, pillow, heel protector, air mattress) Turning the patient frequently Q2H

Question 28

Factors affecting personal hygiene

Answer 28

Cultures (Shower habits) Socioeconomies (Poor may have limited access to shower) Spiritual practices Health states Post-surgery reduce ability to perform hygiene Personal preference (Shower or bathing, soap or liquid soap)

Question 29

Bathing technique

Answer 29

Up to down, clean to dirty Use separate wipes for different body area Keep warm by limiting body exposure Change bed sheet if needed

Question 30

Prevention of scabies

Answer 30

Personal hygiene( hand hygiene ) frequently Change cloth frequently Do not share clothes and personal items Clean carpet regularly

Question 31

Prevention of scabies

Answer 31

Personal hygiene( hand hygiene ) frequently Change cloth frequently Do not share clothes and personal items Clean carpet regularly

Question 32

Assist patient to elimintae in bathroom

Answer 32

Assist weaken patient Ensure handrail in bathroom Never lock door Ensure call bell available

Question 33

Eliminate at bedside

Answer 33

Lock the chair Provide privacy Ensure call bell

Question 34

Prevent injury at work

Answer 34

Good body posture and movement 1. Back straight 2. Avoid body twisting Enhance balance 1. Flex knee to lower gravity 2. Spread feet to shoulder-width to broader base of support Good body movement 1. Use leg or arm muscle (stronger) instead of back muscle 2.