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NUR 102 Final Exam With Complete Solution
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NUR 102 Final Exam With Complete SolutionSupine (Horizontal Recumbent)
-examining the anterior surface
-gown and drape from top down or lap down
Dorsal Recumbent
-comfortable for pts with abdominal or back pain
-drape top to bottom, diamond shape if doing genitalia
-genital and pelvic exams
-drape top to bottom or waist to ankles
Semi-Fowlers
-45 degree angle
-pt with cardiac or respiratory problems
High Fowlers
-90 degree angle
-eating
-cardiovascular or respiratory problems
Prone
-for examining posterior surface of the body
-drape mid-chest down
,Knee-Chest Position
-Rarely used
-Used for proctologic exams and sigmoidoscopy procedures
-Proctologic table has made position unnecessary
-Fenestrated drape covers patient from shoulders to knees
Sims (Lateral)
-Rectal/vaginal exams
-Drape from shoulders to knees
Trendelenburg
-Aid person who is in shock
-Elevate and incline legs
What do you need in order to apply restraints to a patient?
-Doctors order
,Can RN's delegate restraint application to a CNA?
Yes, after RN assessment.
If a patient is in a vest restraint, at what angle should the bed be at all times?
30 degrees
How often should restraints be checked?
15 minutes after initial application, every 1-2 hours after.
What are some alternatives to restraints?
-Alarms
-Family Involvement
-1:1 sitters
-Use of assistive devices
-Strengthening and rehabilitation programs
-Regular attention to toileting and other physical and personal needs
-Relaxed, safe, and comfortable environment
Physical Restraint
Any manual method or physical or mechanical device that restricts freedom of
movement or normal access to body, material or equipment, and that is attached to or
adjacent to the patients body such that the patient can't easily move it.
Chemical Restraint
A medication given to control behavior or movement that is not needed for medical
, treatment.
What's the difference between a safety device and a restraint?
A safety device used for protection, but does not alter/prevent a pt from doing a function
that pt could normally perform.
What are some of the key things to consider when applying restraints?
Quick release knots for emergencies
Tied to bed/chair frame, not side rails/moveable parts
Fit snuggly, not constricting, fit 2 fingers in-between
Vest restraints= 30 degree HOB
Restraint Flow Sheet
Must complete q2h
May require q15 min check when first applied
During checks provide: skin care, ROM exercises, toileting, hydration and nutrition,
ambulation, ASSESS FOR CONTINUATION OF NEED
Why do we restrain pts?
-Danger to themselves or others
-To provide necessary medical treatment
What are some reasons not to restrain a pt?
-Behavior
-Dementia
-Comfort for staff
-Short-staffed
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