Blood Pressure Exam 2

105 Questions | By Coachalan32309 | Updated: Mar 20, 2022 | Attempts: 418

Questions

Settings

Create your own Quiz

Next exam

Questions and Answers

1.
Type Of Dressing Dressing Name Examples About This Dressing Type Of Wound Used For Foam Dressing Allevyn (Smith & Nephew),Biatain(Coloplast),Mepilex/Mepilex Border(Molnlycke),Tegaderm foam(3M)
- Cost effective - can be left in place for up to 7 days
- Promotes a moist wound environment
- Highly absorbent
- Can be used with topical agents
- Comes in a variety of sizes and shapes
- Does NOT provide "padding" for skin
- Mepilex/ Mepilex borderSilicone layer keeps exudate off the wound and periwound skin surface reducing maceration
- Heavily Exudating
- Pressure Ulcer
- Surgical
- Venous Leg Ulcer
- Neuropathic/ Diabetic Ulcer
- Burn
- Donor Site
- Fungating/ Malignant
Calcium Alginate and Hydrofibre* Aquacel/Ribbon(ConvaTec); also a hydrofibre dressing*,Kaltostat(ConvaTec)**
- Can be left on until saturated which depends on wound drainage
- Promotes a moist wound environment
- Interacts with exudate to form a gel*
- Useful for packing wounds
- Always requires a secondary dressing
- Haemostatic
- Moderate/Heavy Exudating wound
- Pressure Ulcer
- Surgical
Hydrocolloid Tegasorb (3M)
- Cost effective – worn up to 7 days
- Promotes a moist wound environment
- Promotes autolytic debridement
- Waterproof and occlusive, which prevents bacterial contamination
- Low Exudating
- Pressure Ulcer
- Venous Leg Ulcer
- First/Second Degree Burn
- Donor Site
- Dry
- Superficial
Hydrogel DuoDerm Gel(ConvaTec),Intrasite Gel(Smith and Nephew)
- Easily removed from wound by irrigation with normal saline/sterile water
- Increases moisture, preventing eschar formation
- In dry wounds can be mixed with Iodosorb and Flagyl
- Promotes autolytic debridement without damaging fragile granulating tissue
- Secondary dressing is required
- Pressure Ulcer
- Surgical
- Venous Leg Ulcer
- Burn
- Malignant
- Dry
- Partial Thickness
- Laceration
- Necrotic
Antimicrobial Dressings/Topical Antimicrobial Preparations Acticoat (Smith and Nephew), Tegasorb Silver (3M), Actisorb Silver (Johnson & Johnson), MepilexAg (Molnlycke), Flamazine(Smith and Nephew), Iodosorb(Smith and Nephew), Medihoney(Derma Science), Mesalt(Molnlycke),Polysporin, Triact silver contact layer(Hollister Wound Care)
- Acticoatremains effective for up to 3 days; use with sterile water not normal saline; can be remoistened
- Actisorb Silvercontains charcoal which absorbs odor and bacterial toxins
- IodosorbAntimicrobial activity is sustained for approximately 3 days; goes on brown, change when cream coloured
- MedihoneyCalcium alginate for wet wounds & honeycolloid for dry wounds and debriding.; quickly reduces odour and useful in all phases of wound healing
- Mesalt is impregnated with sodium chloride (hypertonic solution); use on wet wounds only and change q 24 hours
- Triact Silver Contact Layerhelps avoid maceration; allows exudate to pass through into outer absorbent layer; does not adhere to wounds and therefore less painful during removal
- Moderate/High Exudating
- Pressure Ulcer
- Surgical
- Venous Leg Ulcer
- Diabetic Ulcer
- Burn
- Infected
- Sloughy or Infected wounds
- Fungating exogenous tumours (commonly from late stage breast cancer)
- Cellulitis (Triact)
Skin Protectant No Sting Barrier(3M), Proshield(Healthpoint)
- Provides 24 hour incontinence protection
- Periwound skin protectant
- Reduces friction and shear
- Does not require a cover dressing
- Protects intact or damaged skin from bodily fluids, adhesives, and friction
- Proshield can be used up to and including Stage ll pressure ulcers and fungating wounds
Soft Silicone Dressing Mepitel(Molnlycke)
- Minimizes maceration
- Prevents the cover/secondary dressing from sticking to the wound, minimizing trauma and pain at dressing change
- Can remain intact for up to 7 days (change cover dressing only as needed)
- Second degree burn and chronic wound
- Skin Tear
- Abrasion
- Painful wounds and wounds with compromised surrounding skin
Self Adherent Absorbent Dressing Alldress(Molnlycke), Island Dressing such asMedipore (3M) and Tegaderm(3M)
- Provides a moist wound environment
- Absorbs exudate
- Primary dressing for clean wounds where a barrier is needed
- Secondary dressing for open wounds, for example antimicrobial dressings or calcium alginate/ hydrofiber
- All in one sterile dressings to be used as a primary or secondary dressing
- A combination of a non-adherent pad covered with a waterproof, transparent backing on a soft cloth conformable cover
- Low Exudating
- Pressure Ulcer
- Venous Leg Ulcer
- First/Second Degree Burn
- Donor Site
- Dry
- Superficial
- Infected wound
2.

Perrla stands for pupils equal round, reactive to light and accomodation.
- A.
  
  True
- B.
  
  False
3.

Steps in taking blood pressure.
- A.
  
  Measure cuff size
- B.
  
  Line up cuff point over the brachial artery
- C.
  
  Palpate radial pulse while pumping up cuff
- D.
  
  Palpate brachial pulse
- E.
  
  Move clothing away from BP site
- F.
  
  Wrap cuff snugly around arm approximately 2 inches above elbow crease
- G.
  
  Inflate and obliterate the pulse and remember number
- H.
  
  Deflate cuff and find pulse again.
- I.
  
  Using stethoscope find pulse and reinflate cuff approx 30 mg over obliterated pulse number
- J.
  
  Slowly deflate cuff and rememeber number when you first hear a sound.
- K.
  
  Continue to deflate cuff until the sound disappears or too faint to hear and record upper and lower number.
4.

A consenual reflex means that actions are independent
- A.
  
  True
- B.
  
  False
5.

Convergence is the ability for the eyes to move together on both near and far objects.
- A.
  
  True
- B.
  
  False
6.

What are abnormal findings of the skin?
- A.
  
  Abrasion (bruises, sores)
- B.
  
  Excessive dryness
- C.
  
  Ammonia dermatitis
- D.
  
  Acne
- E.
  
  Erythema Iexcessive redness)
- F.
  
  Hairiness
7.

Abnormal hari dandruff, scabes, lice, ticks,
- A.
  
  Option1
- B.
  
  Option2
- C.
  
  Option3
- D.
  
  Option4
8.

Capillary refill should be
- A.
  
  Less than 3 seconds
- B.
  
  Between 3 and 4 seconds
- C.
  
  Greater than 4 seconds
- D.
  
  Option 4
9.

Therapeutic baths require a physcian's order.
- A.
  
  True
- B.
  
  False
10.

What is detailed in therapeutic bath?
- A.
  
  Type of bath
- B.
  
  Temp of water
- C.
  
  Body surface to be bathed
- D.
  
  Option 4
11.

Types of baths include
- A.
  
  Complete bed
- B.
  
  Self-help
- C.
  
  Partial
- D.
  
  Bag
- E.
  
  Tub
- F.
  
  Sponge
- G.
  
  Shower
- H.
  
  Sprinkler
12.

You can leave your patient unattended any time.
- A.
  
  True
- B.
  
  False
13.

Diabetic patients require special foot care
- A.
  
  True
- B.
  
  False
14.

Discharge planning starts on admission
- A.
  
  True
- B.
  
  False
15.

Patients goals should be
- A.
  
  Specific
- B.
  
  Measuabble
- C.
  
  Achievable
- D.
  
  Realistic
- E.
  
  Timeframe
16.

What is the number one nursing intervention?
- A.
  
  Assess
- B.
  
  Manage
- C.
  
  Plan
- D.
  
  Evaluate
17.

Three layers of skin, epidermis, dermis, subcutaneous tissue.
- A.
  
  Option 1
- B.
  
  Option 2
- C.
  
  Option 3
- D.
  
  Option 4
18.

What does the skin do?
- A.
  
  Regulate temp
- B.
  
  Regulate fluids
- C.
  
  Primary defense against pathogens
- D.
  
  Makes me look good
19.
- A.
  
  Option 1
- B.
  
  Option 2
- C.
  
  Option 3
- D.
  
  Option 4
20.

What does adipose tissue do?
- A.
  
  Provides cushion over bony prominences
- B.
  
  Makes me look fat
- C.
  
  Keeps me warm
- D.
  
  Used to make candles
21.

Nutrition and hydration, bathing strips skin of oil restrict bathing, malnutrition causes the loss of subcutaneous tissue.
- A.
  
  Option 1
- B.
  
  Option 2
- C.
  
  Option 3
- D.
  
  Option 4
22.

As we age the acid mantel is gone making the skin itchy.
- A.
  
  True
- B.
  
  False
23.

We assess skin turgor on elderly at the clavicle or forehead.
- A.
  
  True
- B.
  
  False
24.

The three P's are pressure, pain and potty are assessed every 2 hours.
- A.
  
  True
- B.
  
  False
25.

We are we likely yo get pressure ulcers (bony prominences).
- A.
  
  Sacrum
- B.
  
  Occipitel
- C.
  
  Scapula
- D.
  
  Elbows
- E.
  
  Heels