MDC FINAL EXAM 2022 QUESTIONS AND ANSWERS

1. 1st priority when a client falls when the nurse is not in the room?: check on patient for any injuries 2. What do you do when a client is about to about to fall while the nurse is there?: guide the patient to the floor. 3. Positioning to reduce injury for bony prominences: • Place pillows under areas and elevate • Changes position for 2hrs • Elevate calves to protect heels 4. Reducing shear injury: • Avoid pulling and sliding patient against bed • Keep head of bed at a slight elevation • Make sure sheets and blankets have ripples in them that rub against the patient's skin • Use others to assist to protect from shearing. 5. Reduce urinary tract infection: Proper cleaning of Perineum (front to back) 6. Preventing Pressure Injuries Positioning: • Pad contact surfaces with foam, silicone gel, air pads, or other materials with pressure-redistribution properties. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, position at a 30-degree tilt. • Re-position an immobile patient at a frequency consistent with assessed needs. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a desig- nated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles or a heel-suspension device. 7. Nutrition: • Ensure a fluid intake between 2000 and 3000 mL/day. • Help the patient maintain an adequate intake of protein and calories. 8. Skin Care to prevent pressure ulcer: • Perform a daily inspection of the patient's entire skin • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin and apply when skin is damp • Keep moisture from prolonged contact with skin: • Dry areas where two skin surfaces touch, such as the axillae and under the breasts. • Place absorbent pads under areas where perspiration collects. • Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room. 9. Skin Cleaning (Pressure Ulcer prevention) • Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for inconti- nence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin: - barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talc directly on the perineum. • After cleaning, apply a commercial skin barrier to areas in frequent contact with urine or feces. 10. Intrinsic contributing factors of pressure ulcers: • Immobilization • Cognitive deficit • Chronic illness (eg, diabetes mellitus) • Poor nutrition • Steroid use • Aging 11. Extrinsic Contributing factors to pressure ulcers: • Pressure • Friction • Humidity • Shear force 12. Normal body temperature: 96.4 to 99.5 (depending on the site) 13. Respiration Rate: - 12 to 20 breaths per minute 14. BP: - 120/80 and below; anything higher is abnormal 15. Pulse Ox (saturation): - 94 to 100% 16. Pulse: - 60 to 100 BPM 17. Appropriate measures in taking an oral temperature: • If patiently had food or a drink wait 20 to 30 min before measuring temp • Gently place the oral prob