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Nur125 Exam 2 Questions with Complete
Solution
1. What are some things nurses should assess for in the home environment that could affect
immobility?: Non-skid house shoes Rugs Things in the pathway
2. The bed should always be in this position if the patient is lying in it?: Low locked position
3. What is the largest organ of the body?: Skin
4. How many stages are there to stage or classify the wound?: 4 stages
5. This is the difference between acute vs chronic wounds?: Acute: Develop as a result of injury and typically a result
of trauma. Chronic: develop over time from acute wounds that do not progress in healing
6. The systematic approach to completing a bed bath?: Head to toe (face first) Clean to dirty
7. This can cause a blood clot in veins if not ambulated immediately after surgery?: Deep vein
thrombosis (DVT) - can occur when people are immobile
8. These things should be near the patient before the nurse or healthcare professional walks
out the room?: Call-light Bedside table Bedside
2 / commode Tissues Cell phone Any personal possessions that the client requests
9. The skin protects how much of the body?: 15%
10. Full thickness skin and tissue loss, what stage of pressure ulcer?: Stage 4 - Tissue loss
11. 2 ways that wounds are treated?: -Surgical debridement (Removal of dead or unhealthy tissue from wound)
-Wound dressings
12. Name 2 subjective assessment examples of hygiene needs: Do you feel you can help with your
hygiene? Do you have any preferences for how you bathe, shampoo, brush your teeth, shave, or care for your feet?
13. Name at least 3 effects of immobility on body: Decreased muscle tone Decrease
joint mobility and flexibility Activity tolerance Bone demineralization Altered gate Unbalance coordination
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2. Provide supportive devices (overlays, mattress covers, specialty beds, foams, gels, air cushions).
3. Maintain skin hygiene (implement active and passive range of motions, don't massage bony prominences).
4. Encourage proper nutrition (protein, hydrations, vitamins A, C, zinc, copper).
18. The difference between a complete and partial bath?: Complete: bath administered to totally dependent
patient in bed. Partial: Dependent patients in need of partial hygiene or self-suflcient bedridden patients who are unable to reach all body parts.
19. Name 3 extrinsic factors that can influence client safety related to mobility
in the clinical environment: Smoking Food Beverage Water Communication issues Education Competency
20. True or False: The nurse should leave the client in bed to prevent falls: False
Patients need to ambulate to maintain strength and to avoid complications of bed rest
21. Risk factors for aging skin?: Immobility
Incontinence Vascular disorders Obesity
5 / Inadequate nutrition (protein) Hydration Anemia Fever Dehydration Impaired circulation Edema Sensory deficits Impaired cognition Chronic disease (DM, COPD, CHF) Sedation Opiate use
22. How can the nurse determine if a person of color has a pressure injury?: Skin
temperature Moisture Skin hardness
23. How often should we turn a patient: Recommend at least every two hours;
however, we should review the patients condition to determine if we need more or less due to frequency (individualize it)
24. Name 3 older adult considerations for hygiene care: Skin is thinner, drier, and will tolerate
as much bathing as a younger adult
7 / Moisture E: Edge of wound (Describe wound damage)
29. The role of a wound care nurse: -Assess deep wounds, skin teas, ostomies, diabetic foot wounds, burns.
-Educate statt -Create, update, and manage care plans -Work with multidisciplinary team -Perform diabetic foot care
30. The nurse should check these hemodynamics to see if the client is tolerating the physical
activity of bathing: Vital signs
31. Why are older adults at risk for falls?: Progressive bone loss
Decreased physical activity Weaker bones Walk slower Side ettect of medications
32. A client who falls may result in: Fracture
Longer hospital stays Bruises Lacerations Internal bleeding Death
33. Why do pressure ulcers occur?: Unrelieved and/or prolonged pressure
Combination of shear
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34. Skin looks soggy, feels moist, soft, and more white than usual: Skin maceration
35. This position avoids the bony prominences of the body: 30 degree lateral (side)
36. Good oral care is important due to these reasons: Prevent pneumonia from clients recovering from
stroke and dementia Prevent aspiration
37. This age group has an awkward posture because the head and upper trunk are carried
forward and can lead to being off balance and falls: Toddlers/Infants
38. Name 3 universal fall precautions: Familiarize patient with environment Maintain
call light in reach Keep personal possessions within reach Hospital bed brakes locked Wheelchair brakes locked Non- slip footwear Follow safe patient handling practices Keep floor clean and dry Use night lights and supplementary lights
39. True or False: Medical devices can cause pressure ulcers?: True
Pressure can be caused by a medical device such as a urinary catheter, oxygen tubing, ET tubes, drain, and a call light.
40. Name 3 things that can affect skin healing: Age Overall
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5. Callouses
43. These alterations can lead to a clients immobility: Balance and alignment Gravity and
friction Skeletal muscle Nervous system
44. Name 5 risk factors that nurses can assess to determine a patients risk for
falls?: Perception of safety Lifestyle (social activities, medical devices, ADLs, car and motorcycle) Medication history History of falls Home maintenance and safety
45. Name 5 categories that are utilized to assess the skin on the Braden Scale: -
Sensory perception Moisture Activity Nutrition Friction and shear
46. A combination of primary and secondary healing, where the wound is left open for 5-
10 days before it is closed with sutures: Tertiary
47. This is how the nurse prevents herself from injury when moving the patient-
: Good body mechanics!
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1. Maintain correct body alignment
2. Good balance
3. Use large muscle groups in legs for movement
4. Perform work at appropriate height for ones body
5. Use mechanical lifts
48. Nursing interventions for bed making: 1. Keep client bed clean and comfortable
2. Follow medical asepsis
3. Determine the best time to make bed
4. Change any linen ASAP when wet or soiled
