acde The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching: a. turning patients at least every 2 hours b. rubbing redd...
NUR 336 Final Exam Questions and
Correct Answers
acde ✅The nurse is teaching the nursing assistive personnel (NAP) in a nursing home
about daily routine measures to reduce the incidence of pressure injuries within the
agency. Which of the following should the nurse include in the teaching:
a. turning patients at least every 2 hours
b. rubbing reddened bony prominence
c. use of pillow bridging when needed
d. positioning patient in the 30 lateral position
e. using a turn sheet to reposition patients
f. decreasing patients' fluid intake to decrease incidence of incontinence
all ✅The daughter of an elderly patient comes to visit her mother, who was recently
admitted to the hospital. The daughter notices a yellow band on her mother's wrist and
asks what it is for. The nurse correctly responds that it is used to identify patients who
are at risk for falling and provides additional information as to what makes a patient a
fall risk. What information should the nurse include? SATA
a. Age over 65
b. New and different environment
c. Having an iv, history of a fall, taking muscle relaxants
a ✅which of the following can be delegated?
a. transfer from bed to chair
b. determining a dependent patient's risk for aspiration
c. completing a fall risk assessment tool
d. applying restraints
ad ✅The nurse is caring for an elderly person who has suffered a stroke and now has
left-sided weakness and dysphagia. The nurse is being careful to prevent the patient
from aspirating by taking which of the following measures?
a. having patient maintain upright position for 30 to 60 minutes after eating
b. placing food on patients left side of mouth
c. placing the food in the middle of tongue toward back of mouth
d. having patient tilt her head forward slightly when swallowing
Stage 1 (non-blanchable erythema with intact skin), Stage 2 (partial-thickness loss as a
shallow open injury), Stage 3 (Full-thickness skin loss, subcutaneous fat may be
visible), Stage 4 (Full-thickness tissue loss with exposed bone, tendon, or muscle)
✅explain stages of pressure ulcers
all but WBC ✅Which of the following lab results or measurements indicate a risk for
impaired wound healing?
, a. a BMI of 35 (elevated)
b. fasting BG of 215mg/dL
c. serum albumin of 2.9 (decreased)
d. hemoglobin of 10g/dL (decreased)
d. normal WBC
To wash hands with soap and water before and after caring for patients with C. difficile.
✅A patient has a diagnosis of Clostridium difficile. What is most important for the nurse
to convey to the NAP regarding this patient's care?
20 minutes ✅The NAP is preparing to measure a patient's vital signs. The patient
reports having eaten a bowl of warm soup. The NAP asks the RN what he should do.
What is the best response?
"Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's
oral temperature."
"Since the soup was not hot, go ahead and take the patient's temperature."
"Change to the red thermometer probe and take the patient's temperature rectally."
"Take the patient's temperature using the axillary route and when you record the
reading, add 1°F."
ASSESS ✅The NAP reports to the nurse the patient's respirations are 32 and the
patient is complaining of shortness of breath. What is the best action by the nurse at this
time?
Request the NAP obtain the patient's pulse oximetry and report back.
Ask the NAP to obtain and document a full set of vital signs.
Assess the patient, including the pulse oximetry reading.
Notify the health care provider of this change in condition
all but the last 2 ✅The nurse is having great difficulty hearing any sound when taking a
patient's BP. What can the nurse do to increase the ability to auscultate the reading?
Reduce environmental noise by turning off the TV or closing the door.
Make sure the stethoscope does not touch the patient's clothing or BP cuff.
Keep the stethoscope tubing still to avoid extraneous sound.
Ensure the chest piece is rotated to the diaphragm side.
Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
Use a different stethoscope with longer tubing for improved conduction of sound.
Use the bell side of the stethoscope to auscultate the blood pressure.
apical ✅A nursing student is assigned to take the vital signs on a patient and finds the
radial pulse to be irregular. What action should the nursing student take?
Ask a fellow student to assess the pulse.
Auscultate the patient's apical pulse.
Wait 15 minutes and reassess the pulse.
Check the patient's previous pulse reading.
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