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RNSG [] 1105 [] Nursing [] Skills [] Exam [] 2 [] Review []
(Module [] 6) [] questions [] & [] answers
Remember [] you [] always [] start [] out [] with [] - [] Correct [] answer [] ✔educating [] your [] patient [] & [] telling [] them [] what [] you [] are [] going [] to [] do Always [] remember [] - [] Correct [] answer [] ✔cultural [] differences [] (like [] when [] they [] want [] a [] bath [] or [] not--only [] have [] to [] give [] it [] if [] they [] have [] an [] infection/skin [] breakdown [] & [] they [] need [] a [] bath) Standard [] Precautions [] (medical [] asepsis) [] - [] Correct [] answer [] ✔Handwashing [] and [] gloves [] (non [] sterile) [] any [] time [] the [] nurse [] may [] come [] into [] contact [] with: [] blood [] body [] fluids [] secretions [] / [] excretions [] non-intact [] skin [] mucous [] membranes When [] to [] wear [] gloves/not [] in [] reference [] to [] hygiene [] - [] Correct [] answer [] ✔wear [] gloves [] for [] soiled [] linens
Wash [] with [] antimicrobial [] soap [] - [] Correct [] answer [] ✔when [] there [] is [] visible [] contamination [] & [] handling [] bodily [] fluids [] (before [] putting [] on [] new [] gloves) at [] beginning [] and [] end [] of [] shifts, before [] and [] after [] wearing [] gloves [] for [] patient [] care [] or [] handling [] contaminated [] patient [] items. Use [] Alcohol-based [] hand [] rubs [] - [] Correct [] answer [] ✔when [] hands [] are [] not [] considered [] contaminated [] Ex. [] Before [] and [] after [] taking [] vital [] signs Hand [] hygiene [] - [] Correct [] answer [] ✔Before [] & [] after [] care Before [] & [] after [] each [] patient wear [] gloves [] for [] soiled [] linens Rationale [] for [] Personal [] Hygiene [] - [] Correct [] answer [] ✔Stimulates [] circulation: [] distal [] to [] proximal [] gentle [] strokes [] and [] warm [] water [] stimulate [] circulation [] and [] promote [] venous [] return. Helps [] improve [] self-image: [] Promote [] patient [] independence [] encourage [] them [] to [] do [] what [] they [] can. Opportunity [] for [] Assessment: [] patient [] condition, [] psychosocial [] / [] learning [] needs, [] signs [] of [] skin [] breakdown.
secretions [] from [] the [] eyes; [] boric [] acid [] not [] necessary [] and [] might [] damage [] eye [] leading [] to [] entry [] point [] for [] infection. Ears [] - [] Correct [] answer [] ✔turn [] it [] off [] first Clean [] the [] patient's [] external [] ear [] with [] a [] washcloth-covered [] finger. [] ONLY [] the [] external [] ear [] (front [] and [] back) [] is [] washed; [] at [] least [] daily [] with [] a [] washcloth-covered [] finger; [] sharp [] objects [] could [] injure [] the [] ear. [] Q [] tips [] or [] cotton [] swabs [] cause [] cerumen [] (ear [] wax) [] to [] become [] packed [] further [] into [] the [] inner [] ear. Hearing [] Aids [] - [] Correct [] answer [] ✔Ask [] Pt. [] / [] Family [] about [] removal [] of [] hearing [] aid. [] Newer [] models [] do [] not [] need [] to [] be [] turned [] off [] prior [] to [] removal. Turn [] off [] prior [] to [] removing. Wipe [] with [] dry [] cloth [] to [] remove [] body [] oils [] or [] cerumen. Reinsert [] hearing [] aid [] while [] pulling [] earlobe [] downward. [] Turn [] on [] and [] adjust [] volume. Safety [] Alert! [] Ask [] the [] patient [] if [] comfortable [] and [] can [] they [] hear! Position [] and [] supplies [] needed [] for [] the [] unconscious [] patient [] (Oral [] Care) []
- [] Correct [] answer [] ✔basin
yaunker [] suctioner tongue [] depressor [] lateral [] (left) [] position--tilt [] face [] toward [] mattress Suction [] equipment [] and [] oral [] suction [] device [] (Yaunker) [] must [] be [] hooked [] up [] and [] turned [] on [] prior [] to [] starting [] oral [] care. Use [] small [] amounts [] of [] water [] with [] oral [] suction [] --No [] more [] than [] 5 [] ml [] at [] a [] time. If [] the [] patient [] has [] to [] has [] his [] head [] elevated, [] use [] high [] fowler's [] and [] tilt [] the [] head [] forward [] & [] down. Dentures [] - [] Correct [] answer [] ✔Place [] a [] washcloth [] in [] the [] sink [] to [] prevent [] dentures [] from [] being [] damaged [] if [] dropped [] during [] cleaning. Provide [] privacy [] while [] the [] patient [] removes [] dentures [] from [] the [] mouth. Use [] a [] toothbrush [] and [] paste [] and [] gently [] brush [] all [] surfaces. What [] to [] ask/check [] before [] shaving? [] - [] Correct [] answer [] ✔Are [] they [] on [] blood [] thinners/anticoags? What [] are [] their [] coag [] levels? Do [] they [] have [] diabetes? Do [] you [] have [] a [] bleeding [] disorder? How [] to [] Shave [] with [] a [] Safety [] Razor [] - [] Correct [] answer [] ✔Soften [] Beard [] first [] with [] warm, [] wet [] cloth
free [] of [] wrinkles. [] length [] and [] circumference [] measured [] for [] correct [] size. [] (too [] tight--if [] not [] monitored, [] can [] cut [] off [] circulation, [] too [] large--patients [] wasting [] money, [] too [] small--can [] cause [] DVT) Patient [] SHOULD [] ambulate [] with [] them [] on
- [] Insert [] hand [] into [] stocking [] as [] far [] as [] the [] heal [] pocket
- [] Grasp [] the [] center [] of [] the [] heel [] pocket [] and [] turn [] stocking [] inside [] out [] to [] heel [] area
- [] Carefully [] position [] stocking [] over [] foot [] and [] heel. [] Be [] sure [] heel [] is [] centered [] in [] heel [] pocket.
- [] Begin [] pulling [] body [] of [] stocking [] up [] around [] the [] ankle [] and [] calf..
- [] Smooth [] stocking [] up [] to [] just [] below [] knee. [] If [] measured [] properly, [] the [] stocking [] will [] fit [] smoothly. [] Be [] sure [] not [] to [] roil [] down [] top [] of [] stocking [] (acts [] like [] a [] tourniquet) TED [] Hose [] Neuromuscular [] Checks [] - [] Correct [] answer [] ✔Assess: [] NEURO- VASCULAR [] checks [] Q [] 8 [] and [] PRN. [] Neuro- [] (nerves) Wiggle [] toes [] Numbness [] / [] tingling [] / [] swelling. [] Vascular [] (circulation) Toes [] warm [] and [] pink [] ((or [] normal [] for [] ethnicity) Capillary [] refill [] < [] 3 [] secs.(press [] on [] toe [] nail [] and [] begin [] counting) []
- [] Remove [] Q [] SHIFT: [] Assess [] for [] signs [] of [] skin [] breakdown [] or [] DVT [] then [] reapply. Capillary [] refill [] assesses [] how [] quickly [] circulation [] returns [] to [] the [] toe [] nail [] or [] skin [] after [] it [] is [] pressed [] hard [] enough [] to [] cause [] blanching. [] Counting [] is [] One [] one [] thousand, [] Two [] one [] thousand, [] etc. [] If [] the [] blanched [] area [] becomes [] pink [] again [] within [] 3 [] seconds [] Cap [] Refill [] is [] said [] to [] be [] good [] (< [] 3 [] sec.). [] Longer [] than [] that [] indicates [] poor [] circulation. [] Be [] sure [] to [] check [] chart [] for [] prior [] assessments [] to [] identify [] changes. [] If [] your [] findings [] are [] new, [] may [] need [] to [] recheck [] the [] fit. [] Any [] change [] in [] circulation [] is [] important [] to [] report [] to [] the [] HCP [] and [] document. [] It [] is [] best [] to [] replace [] the [] TEDs [] at [] the [] end [] of [] the [] bath [] before [] getting [] the [] patient [] out [] of [] bed. [] Their [] lower [] legs [] may [] swell [] upon [] becoming [] dependent [] (lower [] that [] the [] trunk [] of [] the [] body). [] If [] this [] happens, [] you [] will [] need [] to [] put [] them [] back [] in [] bed [] and [] elevate [] their [] legs [] for [] at [] least [] 20 [] minutes [] to [] resolve [] swelling [] before [] reapplying [] the [] TEDs. Get [] 2 [] pairs [] of [] TEDs [] for [] your [] patient. [] That [] way [] you [] can [] rinse [] out [] the [] old [] ones [] and [] put [] on [] fresh [] ones [] each [] day [] with [] their [] bath. [] Patients [] can [] take [] their [] TEDs [] home [] with [] them [] when [] they [] are [] discharged Sequential [] Compression [] Device [] (SCD) [] - [] Correct [] answer [] ✔Plastic [] sleeve [] wrapped [] around [] leg, [] Velcro [] fastening Connected [] to [] pump, [] alternately [] inflates [] / [] deflates [] sleeve [] (ankle [] to [] top)
To [] respond [] to [] Mrs. [] K [] : [] I [] will [] gladly [] explain [] the [] correct [] way [] to [] trim [] your [] toenails [] but [] because [] of [] the [] risk [] for [] injury [] to [] the [] toe [] and [] subsequent [] infection, [] ACC [] Nursing [] students [] may [] not [] trim [] toenails. The [] correct [] way [] to [] trim [] nails [] is [] to [] cut [] them [] straight [] across [] and [] away [] from [] the [] end [] of [] the [] nail [] bed. [] Cutting [] them [] too [] short [] can [] cause [] ingrown [] toenails. Male [] Perineal [] Care [] - [] Correct [] answer [] ✔Remember [] "Clean [] to [] Dirty" Uncircumcised [] male [] patient [] (teenage [] and [] older) [] retract [] foreskin [] to [] wash [] the [] glans. IMPORTANT [] Pull [] foreskin [] back [] into [] place [] Immediately [] to [] prevent [] constriction [] of [] the [] shaft, [] edema, [] & [] serious [] tissue [] damage. Indwelling [] Foley [] catheter: Clean [] the [] first [] several [] inches [] of [] the [] catheter [] tubing [] from [] the [] meatus [] toward [] the [] drainage [] bag. [] To [] prevent [] dislodging [] the [] catheter, [] hold [] it [] between [] two [] fingers [] at [] the [] meatus [] as [] you [] are [] wiping. Female [] Perineal [] care [] - [] Correct [] answer [] ✔Clean [] front [] to [] back [] to [] prevent [] carrying [] organisms [] from [] the [] anal [] area [] back [] over [] the [] genital [] area. [] If [] there [] is [] an [] indwelling [] catheter, [] clean [] several [] inches [] of [] the [] tubing [] while [] holding [] it [] where [] it [] exits [] the [] meatus [] toward [] the [] drainage [] bag.
Condom [] Catheter [] - [] Correct [] answer [] ✔Safer [] alternative [] to [] indwelling [] catheter [] (Foley) [] for [] male [] incontinence. [] (NPSG [] 7: [] Prevent [] CAUTI) Leave [] 1 [] to [] 2 [] inches [] (2.5 [] to [] 5 [] cm) [] of [] space [] between [] tip [] of [] penis [] and [] end [] of [] condom [] sheath. Ensure [] the [] tubing [] is [] not [] kinked [] or [] twisted. [] Hang [] the [] drainage [] bag [] on [] the [] bed [] frame [] below [] the [] bladder. [] If [] your [] patient [] is [] uncircumcised, [] be [] sure [] the [] foreskin [] is [] pulled [] forward [] before [] applying [] the [] condom. [] Put [] the [] tape [] in [] a [] spiral [] around [] the [] penis [] and [] never [] wrap [] the [] actual [] penis [] without [] the [] condom [] on [] it [] bc [] it [] cuts [] off [] circulation. Rationale [] for [] Changing [] Linen [] - [] Correct [] answer [] ✔Psychological [] : [] Promotes [] Comfort Patient [] feels [] comfortable [] and [] refreshed. Physiological [] : [] Preserve [] Skin [] Integrity Food [] Crumbs, [] rough [] seams [] and [] wrinkles [] cause [] skin [] irritation [] and [] contribute [] to [] pressure [] sores/decubitus. Safety [] / [] Environmental: [] "Break [] the [] chain" Soiled [] linens [] are [] a [] Reservoir [] for [] microorganisms. Maintain [] Asepsis [] - [] Correct [] answer [] ✔Hand [] Hygiene [] - [] wear [] gloves [] for [] soiled [] linens
Review [] performance [] checklists [] on [] everything [] - [] Correct [] answer [] ✔ What [] is [] the [] proper [] position [] to [] use [] for [] an [] unresponsive [] patient [] during [] oral [] care [] to [] prevent [] aspiration? [] - [] Correct [] answer [] ✔Sim's [] position Semi-Fowler's [] position [] with [] head [] to [] the [] side. The [] student [] nurse [] is [] teaching [] a [] family [] member [] the [] importance [] of [] foot [] care [] for [] his [] or [] her [] mother, [] who [] has [] diabetes. [] Which [] safety [] precautions [] are [] important [] for [] the [] family [] member [] to [] know [] to [] prevent [] infection? [] (Select [] all [] that [] apply.) [] - [] Correct [] answer [] ✔Assess [] skin [] for [] redness, [] abrasions, [] and [] open [] areas [] daily. [] Apply [] lotion [] to [] the [] feet [] daily. Clean [] between [] the [] toes [] after [] bathing. A [] nurse [] uses [] long [] firm, [] strokes [] distal [] to [] proximal [] while [] bathing [] a [] patient's [] legs [] because: [] - [] Correct [] answer [] ✔It [] promotes [] venous [] circulation. Integrity [] of [] the [] oral [] mucosa [] depends [] on [] salivary [] secretion. [] Which [] of [] the [] following [] factors [] impairs [] salivary [] secretion? [] (Select [] all [] that [] apply). []
- [] Correct [] answer [] ✔Radiation [] therapy Dehydration
A [] nurse [] is [] assigned [] to [] care [] for [] the [] following [] patients. [] Which [] of [] the [] patients [] is [] most [] at [] risk [] for [] developing [] skin [] problems [] and [] thus [] requiring [] thorough [] bathing [] and [] skin [] care? [] - [] Correct [] answer [] ✔A [] 70 [] year-old [] patient [] who [] has [] diabetes [] and [] dementia [] and [] has [] been [] incontinent [] of [] stool. When [] you [] are [] assigned [] to [] a [] patient [] who [] has [] a [] reduced [] level [] of [] consciousness [] and [] requires [] mouth [] care, [] which [] physical [] assessment [] techniques [] should [] you [] perform [] before [] the [] procedure? [] (Select [] all [] that [] apply.) [] - [] Correct [] answer [] ✔Respiration Gag [] reflex A [] nurse [] is [] listening [] to [] a [] student [] provide [] instruction [] to [] a [] patient [] who [] is [] having [] difficulties [] with [] activities [] needed [] to [] care [] for [] soft [] contact [] lenses. [] Which [] of [] the [] following [] statements [] by [] the [] nursing [] student [] might [] require [] some [] correction [] by [] the [] nurse? [] - [] Correct [] answer [] ✔Use [] tap [] water [] to [] clean [] soft [] lenses. The [] American [] Dental [] Association [] suggests [] that [] patients [] who [] are [] at [] risk [] for [] poor [] hygiene [] use [] the [] following [] interventions [] for [] oral [] care. [] (Select [] all [] that [] apply.) [] - [] Correct [] answer [] ✔Use [] antimicrobial [] toothpaste. Use [] 0.12% [] chlorhexidine [] gluconate [] (CHG) [] oral [] rinses. Use [] a [] soft [] toothbrush [] for [] oral [] care.
- [] Gently [] brush [] tongue [] but [] avoid [] stimulating [] gag [] reflex. []
- [] For [] patients [] without [] teeth, [] use [] a [] toothlette [] moistened [] in [] chlorhexidine [] rinse [] to [] clean [] oral [] cavity. The [] nurse [] delegates [] needed [] hygiene [] care [] for [] an [] elderly [] stroke [] patient. [] Which [] intervention [] would [] be [] appropriate [] of [] the [] nursing [] assistive [] personnel [] to [] accomplish [] during [] the [] bath? [] - [] Correct [] answer [] ✔Providing [] range-of-motion [] (ROM) [] exercises [] to [] extremities. The [] nurse [] observes [] an [] adult [] Middle [] Eastern [] patient [] attempting [] to [] bathe [] himself [] with [] only [] his [] left [] hand. [] The [] nurse [] recognizes [] that [] this [] behavior [] likely [] relates [] to: [] - [] Correct [] answer [] ✔The [] patient's [] cultural [] norm. When [] a [] nurse [] delegates [] hygiene [] care [] for [] a [] male [] patient [] to [] a [] nursing [] assistive [] personnel, [] the [] NAP [] must [] use [] an [] electric [] razor [] to [] shave [] the [] patient [] with [] the [] following [] diagnosis: [] - [] Correct [] answer [] ✔Thrombocytopenia A [] patient [] receiving [] chemotherapy [] experiences [] stomatitis. [] The [] nurse [] advises [] the [] patient [] to [] use: [] - [] Correct [] answer [] ✔Normal [] saline [] rinses.
