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Summary NUR 2356 / NUR2356: Multidimensional Care I / MDC 1 Final Exam 3 (Latest 2021 / 2022) Rasmussen College $13.99   Add to cart

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Summary NUR 2356 / NUR2356: Multidimensional Care I / MDC 1 Final Exam 3 (Latest 2021 / 2022) Rasmussen College

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MDC Final Exam Review 1. Appropriate nursing actions: Nicole a) When a client falls  1 st priority – check on patient for any injuries Before that, guide the patient to the floor. b) Positioning to reduce injury for bony prominences  Place pillows under areas and elevate  Changes...

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  • July 28, 2022
  • 17
  • 2021/2022
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Summary NUR 2356 / NUR2356: Multidimensional Care I / MDC 1 Final Exam 3 (Latest ) Rasmussen College




MDC Final Exam Review

1. Appropriate nursing actions: Nicole

a) When a client falls
 1st priority – check on patient for any injuries
Before that, guide the patient to the floor.

b) Positioning to reduce injury for bony prominences
 Place pillows under areas and elevate
 Changes position for 2hrs
Elevate calves to protect heels

c) Reducing shear injury (med surg pg 447)
 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.

d) Reduce urinary tract infection
 Proper cleaning of Perineum – front to back

e) Reducing pressure ulcers- factors that are contributors (med surg pg 448)

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 designated 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.

Nutrition
 Ensure a fluid intake between 2000 and 3000 mL/day.
 Help the patient maintain an adequate intake of protein and calories.

Skin Care
 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.

Skin Cleaning
 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 incontinence.
 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.

f) For vital signs out of range (i.e low oxygen saturation) (module 1 slide 56-59)
 Normal body temperature 96.4 to 99.5 (depending on the site)
 Respiration Rate – 12 to20 breaths per minute
 BP – 120/80 and below; anything higher is abnormal
 Pulse-Oximetry (saturation) – 94 to 100%
 Pulse – 60 to 100 BPM

g) Appropriate measures in taking an oral temperature (module 1 slides55)




h) Vital signs that can indicate post-surgical pain?

,  Elevated Heart Rate
 Breathing rate can be elevated
 Elevated BP


2. Describe the following: Nicole
a) Complications of amputations and type of pain (module 1 slide 10)
Possibility of phantom pain

b) Autonomy for a client requiring oral care (funds book pg 594-595)
 Brush the teeth twice a day.
 Use a soft toothbrush.
 Moisturize oral mucosa and lips every 2 to 4 hours.
 Use a chlorhexidine gluconate (0.12%) rinse twice a day during the perioperative period
for patients who undergo cardiac surgery (adult patients).
 Use mouthwash inside the mouth twice a day for adult patients who are on a ventilator.
 Give the patients the oral supplies


c) Fire safety measures and priorities (module 3 slides 12 &22)
o Fires
 Home fires are the major cause of death and injuries
 Older adults & children < 5y/o have the highest risk.
 Most common causes of fires:
 Cooking fires
 Smoking
 Heating Equipment
 Home oxygen administration equipment: 75% of home fires involves
oxygen, smoking materials are the ignition source
 Remove the client from the area
o RACE
 Rescue – remove patient from danger
 Alarm – pull the alarm
 Contain - close doors
 Extinguish fire (if possible)
o PASS
 Pull the pin
 Aim at the base of the fire
 Squeeze the handles
 Sweep back and forth


d) Infant safety- education for new moms in keeping babies safe.
 Don’t Sleep with baby
 Car seat faces backwards for 2 years
 Baby should sleep in their back

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