PCC study final exam questions &
answers 2024/2025
Assessment: collect data, use evidence-based assessment techniques, document relevant data
Diagnosis: compare clinical findings with normal/abnormal variation & developmental events, interpret
data, validate diagnoses, document diagnoses
Planning: establish priorities, develop outcomes, set timelines for outcomes, culturally appropriate,
realistic and measurable, include a timeline
Implementation: in a safe & timely manner, use evidence-based interventions, collaborate w/ colleagues,
use community resources, coordinate care delivery, provide health teaching & health promotion,
document implementation and any modification
Evaluation: progress towards outcomes, conduct criterion-based evaluation, include pt. and significant
others, use ongoing assessment to revise diagnoses, outcomes, plan, disseminate results to pt. and
family - ANSWERSWhat is the nursing process?
falls - ANSWERSa major health problem esp 65 or older falls are the leading cause of fatal and nonfatal
injuries
Numerous factors increase the risk of falls, including a history of falling, being age 65 or older, reduced
vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary
incontinence, improper use of walking aids, and the effects of various medications.
Falls are also a common problem in health care settings
Minor to severe injury
Underlying disease more susceptible to injury
Interventions
Close proximity, signage, improved hand-offs, nurse toilet/comfort safety rounds, involving family in care
,Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure Ulcer Stage III or IV
Falls and trauma
Catheter associated UTI
Vascular catheter-associated infection
Manifestations of poor glycemic control
Surgical site infections following:
Mediastinitis following coronary artery bypass graft
Orthopedic procedures of spine, neck, shoulder, elbow
Bariatric surgery for obesity (laparoscopic gastric bypass, gasteroenterastomy, laparoscopic gastric
restrictive sleeve)
Cardiac implantable medical device
DVT, PE following knee or hip replacement
Iatrogenic pneumothorax with venous catheterization - ANSWERSWhat are the "never ever" events?
Adequate lighting- orient to surroundings
Remove obstacles from halls and traffic areas
Throw rugs
Necessary patient items on bedside table within reach
Nonessential items away to decrease clutter
No scatter rugs at home or be sure secure with non-skid back
Electronic safety alert device if at risk at home and alone
Yellow wristbands traditionally mean fall risk
Adequate footwear, armbands, surroundings, call light, side rails - ANSWERSfall interventions
, Must be clinically justified
Have to have one of the uses for restraints, have to have tried alternatives
MD order required- based on face-t0-face assessment
Order must be current
Must specify duration and circumstances restraint is used
State a specific time frame as per facility policy
8 hours adults
2 hours 9-17
1 hour under 9
On-going assessment
Bc of complications, must assess for them and release restraints, take off and get person up, see if they
still need them
Document
Behaviors of need
Procedure used in restraining
Condition of body restrained
Evaluation of patient response
Removed Periodically and determine need to continue
May not be ordered PRN
Consent if necessary - ANSWERSrestraint orders
alarms: Weight and motion sensor mats on beds and chairs
Can be silent or audible alarms with pressure changes
Door alarms, Help with confused patients; *alarms are considered restraints In long term care facilities*
side rails: Increase patient mobility and stability
Most commonly used physical restraint
Can cause falls or death
Not typically used in long term care facilities for this reason
