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PNC 100 test 1 set 2 Questions and Answers with complete actual solution
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PNC 100 test 1 set 2 Questions and Answers with complete actual solution
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PNC 100 test 1 set 2✅✅-any food the pt is requesting
A regular diet includes -
accidents that may happen to a patient - ✅✅-falls; burns; cuts
administering an enema - ✅✅-left sims
slow deep breaths
lubricate tip
insert 3-4 inches
container 12-18 inches above rectum
administer 1000mL over 5-10 mins
alternative SRD's - ✅✅ -reality orientation
family visits
1:1 staffing
assign room near nurse station
provide visual / auditory stimuli (activities / jobs)
eliminate unnecessary treatments
use relaxation techniques
evaluate medications
work with PT's and OT's
basic guidelines for SRD's - ✅✅ -use only when needed
attach to moveable part of bed frame
never attach to side rail
quick release knot
asses frequently
discontinue use ASAP
before administering an enema... - ✅✅-1.
2.
3.
4. have a BSC
Braden Scale - ✅✅-assess the pt's risk for skin breakdown; score of 14 or less indicates a
risk
carminative enema - ✅✅-help expel flatus from the rectum
catheter care - ✅✅-The cleansing and care of catheter site.clean 4 inches from the
insertion
Cleansing emema - ✅✅-water or saline
Clear liquid diet includes - ✅✅-Gelatin, popsicles, team, ginger ale, fruit juice without pulp,
bouillon. Milk and juice with pulp are prohibited.
, complete bath - ✅✅-Total body area washed. Usually refers to bed bath.
cool water bath - ✅✅-Water is tepid 98.6 F; relieves tension or lowers body temperature.
deep tissue pressure injury - ✅✅-Intact or non-intact skin with localized area of persistent
non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a
dark wound bed or blood filled blister.
ear care -✅✅-cleanse outside only with washcloth of cotton swab
eye care - ✅✅-plain, clear water; cleanse from inner to outer eye using a separate
washcloth for each eye
female perineal care - ✅✅ -clean front to back
assess for drainage, irritation, skin, odor, pain
✅✅
Full liquid diet includes - -milk, yogurt, custard, ice cream, pureed meats and veggies,
veggie juice, cooked refined cereals, pudding
hair care -✅✅-combing, brushing, shampooing
hand, foot and nail care - ✅✅--Hands and feet often require special attention to prevent
infection, odors and injury
Assessment:
-Examine all skin surfaces
-Carefully assess between toes
-Observe for adequate circulation
✅✅-used to relieve muscle soreness or spasms; 113-115 F
hot water bath -
how do pressure sores develop? - ✅✅-pressure on the skin causes blood vessels to
break; decrease in blood flow (ischemia); cell necrosis
is a nurse allowed to cur fingernails? - ✅✅-a nurse is never allowed to cut fingernails.
if needed an order needs to be put in
key terms of body mechanical and patient positions - ✅✅-base of support
center of gravity
dorsal/surpine
dorsal recument
fowlers
semi fowlers
semi fowlers
orthopneic
sims
prone
knee-chest
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