Exam (elaborations)
NUR150 Exam 2 with 100% correct answers rated A+
- Course
- Hondros Nursing 150
- Institution
- Hondros College School Of Nursing
NUR150 Exam 2 with 100% correct answers rated A+
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NUR150 Exam 2Used to treat inflammatory responses- decreases edema, muscle spasms, pain, and decreases blood flow
to the area. - correct answer ✔✔Cold and Heat Therapy
when is cold and heat therapy recommended for an injury - correct answer ✔✔first 24 to 48 hours
whose responsibility is it to evaluate proper application, adverse signs and symptoms and is also responsible for the patient's safety - correct answer ✔✔LPN
where should you not apply a cold pack to - correct answer ✔✔red or blue areas
how often should you check the skin of a patient who is using an electrical cooling device or an electrical heating device - correct answer ✔✔every 5 minutes
what are common symptoms when using an electrical cooling device - correct answer ✔✔numbness and
tingling
How long should you leave a cooling device in place - correct answer ✔✔15 to 20 minutes
what are some adverse skin reactions when using a cooling device - correct answer ✔✔mottling, redness, burning, blistering and numbness
what should you record when using a cooling device or heating device - correct answer ✔✔what device you used, location, duration, patient response, patient teaching and patients response to teaching
when should you immediately stop application of a cooling device - correct answer ✔✔areas become mottled, red or blue/purple, or if the patient Is complaining of pain/numbness when should you immediately stop application of a heating device - correct answer ✔✔skin becomes reddened and sensitive to touch, extreme warmth noted at the area, and body part becomes painful to move
How long should you leave the heating device in place - correct answer ✔✔20 to 30 minutes or as prescribed
whose responsibility is it to assess skin areas prior to applications of heating and cooling device and assess for risks - correct answer ✔✔LPN
what is one of the nurse's highest priority of care - correct answer ✔✔prevention and treatment of skin impairment
how often should you reposition a chair bound patient - correct answer ✔✔every hour
how often should you reposition a patient that is bed bound - correct answer ✔✔every 2 hours at a 30 degree angle
whose responsibility is it to properly collect a culture of the pressure ulcer - correct answer ✔✔nurse
how do you properly label a specimen - correct answer ✔✔patients name, medical record number, date of birth, date and time of collection, what the collection is for, your name and initials. send as quickly as possible to the lab
what are anaerobic collections of - correct answer ✔✔inside of body cavities
what are aerobic collections of - correct answer ✔✔wound secretions
occurs when the tissue layers of skin slide on each other , causing subcutaneous blood vessels to kink or stretch resulting in an interruption of blood flow to the skin - correct answer ✔✔shearing force
the rubbing of skin against another surface produces what - correct answer ✔✔friction what are the 2 mechanical factors that play a common role in the development of pressure ulcers - correct answer ✔✔shearing force and friction
which patients are at risk for pressure ulcers - correct answer ✔✔chronically ill, debilitated, older, disabled, or incontinent patients, patients with spinal cord injuries, circulatory impairment or poor overall nutrition
how can the nurse assess a patients skin for skin impairment - correct answer ✔✔blanching the area
a pressure ulcer in a localized area of skin, typically over a bony prominence , that is intact with nonblanchable redness. Areas may be painful, firm, soft, warm or cool compared with adjacent tissue. difficult to detect in patients with dark skin tones - correct answer ✔✔Stage 1
partial thickness loss of dermis. shallow open ulcer, usually shiny or dry, with a red-pink wound bed without slough or bruising. some may present as serum- filled blisters - correct answer ✔✔Stage 2
full tissue thickness loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed. if slough is present it does not obscure the depth of tissue loss. possible undermining and tunneling - correct answer ✔✔Stage 3
full thickness loss with exposed bone, tendon, or muscle. sometimes slough or eschar is present on some parts of the wound. Includes undermining and tunneling. - correct answer ✔✔Stage 4
which stage of pressure ulcer would put a patient at risk for osteomyelitis - correct answer ✔✔stage 4 pressure ulcer
the true depth and stage of this ulcer can not be determined. wound bed is covered by slough this is yellow, tan, gray, green or brown. eschar wound bed is tan, brown or black. stable eschar on the heels provide a natural biologic cover. DO NOT REMOVE IT! - correct answer ✔✔unstageable/unclassified
the wound appears as a localized purple or maroon area of discolored intact skin or a blood filled blister. painful, firm, mushy, boggy, or warm to cool compared with adjacent tissue. the wound is sometimes covered in thin eschar - correct answer ✔✔suspected deep tissue injury
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