Exam (elaborations)
NURSING NUR2356 MDC EXAM 3 REVIEW 12-8-19 already graded A
- Course
- Institution
NURSING NUR2356 MDC EXAM 3 REVIEW 12-8-19 NURSING NUR2356 MDC EXAM 3 REVIEW 12-8-19 NURSING NUR2356 MDC EXAM 3 REVIEW 12-8-19
[Show more]
Seller
Follow
BSNGUIDER
Reviews received
Content preview
1MDC 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
, 2
• 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?
, 3
• 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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller BSNGUIDER. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $16.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
72042 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now