PPNC 2 Exam 1 Questions & Answers 2024/2025
What should you NEVER use restraints for? - ANSWERSpunishment
discipline
coercion
convenience
Why are alternatives to restraints so important? - ANSWERS- pt. becomes weaker with immobilization
- restraint devices increase agitation
- greater ...
What should you NEVER use restraints for? - ANSWERSpunishment
discipline
coercion
convenience
Why are alternatives to restraints so important? - ANSWERS- pt. becomes weaker with immobilization
- restraint devices increase agitation
- greater risk for falling/injuries
- psychological side effects like anger, loss of dignity, depression
Difference between medical/surgical restraints and behavioral restraints - ANSWERS- Medical: pt is at
risk for interruption of medical treatment plan (ex: pulling out tubes)
- Behavioral: risk for harming themselves or others
If in an emergency situation and the patient needs restraints, how soon do you need doctors orders to
keep them on? - ANSWERSwithin an hour
Documentation of behavioral restraints: - ANSWERS- the need for restraints
- alternatives that were applied to avoid usage
- notification of family
- time restraints were initiated/discontinued
- type of restraints
- pt. behaviors while in restraints
- ongoing communication with pt/family about termination of restraints
,How often should the nurse monitor and observe a patient in medical restraints? - ANSWERSevery 2
hours
What should observations include when observing someone in restraints? - ANSWERSrespiratory status
circulation
signs of distress
change in behavior
How often do you need an MD order for medical restraints? - ANSWERSdaily
If a patient has behavioral restraints how often should the nurse and MD reassess the patient? -
ANSWERSRN reassesses every 4 hours, MD every 8 hours
Which complication of wound healing is considered a medical emergency? - ANSWERSevisceration: total
separation of layers with internal viscera protruding through incision
What are the phases of wound healing? - ANSWERSinflammatory/cleansing phase
proliferative phase- granulation
maturation phase (remodeling)
When does the proliferative phase occur? - ANSWERSdays 5-21
Which parts of the body should NOT be stapled? - ANSWERShands, feet, neck, face
Which of the following is correct when obtaining a wound culture by swab?
A. Roll swab around in a pool of exudative material.
B. Swab culture areas where slough or eschar is present.
, C. Roll the swab around the wound edges
D. Swab the wound from margin to margin in a 10 point zigzag pattern - ANSWERSD
What are the nutritional essentials for maintaining skin integrity? - ANSWERSprotein
cholesterol
calorie intakes
vitamin C and minerals
hydration
How would you describe/location an arterial ulcer? - ANSWERSfound over lower legs, ankles, toes and
side of foot.
ulcers appear "punched out" small and round with smooth borders
How do arterial ulcers happen? - ANSWERSinsufficient arterial flow to tissues causes ischemia and
eventually necrosis
What is the most common cause of arterial ulcers? - ANSWERSatherosclerosis
How do venous stasis ulcers form? - ANSWERSdeep vein obstruction, inadequate calf muscle function
What do venous stasis ulcers look like? - ANSWERS- located around inner ankle/lower part of calf
- reddened or brown, edematous
- drainage is moderate-heavy
How are venous stasis ulcers managed? - ANSWERS- debridement
- management
- obtaining moisture balance
- use of appropriate dressings
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