Blood Pressure Exam 2

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Blood Pressure Exam 2 - Quiz

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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

    Correct Answer
    A. True
    Explanation
    Accomodation tests connvergence.

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  • 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.

    Correct Answer(s)
    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.
    Explanation
    The explanation provides a step-by-step guide on how to take blood pressure. It starts with measuring the cuff size and then lining up the cuff point over the brachial artery. Next, the person taking the blood pressure should palpate the radial pulse while pumping up the cuff, followed by palpating the brachial pulse. They should then move any clothing away from the blood pressure site and wrap the cuff snugly around the arm, approximately 2 inches above the elbow crease. The cuff should be inflated to obliterate the pulse, and the number should be remembered. After deflating the cuff and finding the pulse again, a stethoscope should be used to find the pulse and reinflate the cuff approximately 30 mmHg above the obliterated pulse number. The cuff should be slowly deflated, and the number should be remembered when the first sound is heard. Finally, the cuff should be deflated until the sound disappears or becomes too faint to hear, and the upper and lower numbers should be recorded.

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  • 4. 

    A consenual reflex means that actions are independent

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    What happens on one side should happen on the other side equally reactive.

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  • 5. 

    Convergence is the ability for the eyes to move together on both near and far objects.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Convergence refers to the ability of the eyes to turn inward and focus on objects that are close to us. This is necessary for binocular vision and depth perception. When we look at objects that are far away, our eyes are parallel. Therefore, convergence is indeed the ability for the eyes to move together on both near and far objects, making the statement true.

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  • 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

    Correct Answer(s)
    A. Abrasion (bruises, sores)
    B. Excessive dryness
    C. Ammonia dermatitis
    D. Acne
    E. Erythema Iexcessive redness)
    F. Hairiness
    Explanation
    The given answer lists various abnormal findings of the skin including abrasion (bruises, sores), excessive dryness, ammonia dermatitis, acne, erythema (excessive redness), and hairiness. These are all conditions or symptoms that deviate from the normal appearance or condition of the skin. Abrasions and sores indicate damage to the skin, excessive dryness suggests a lack of moisture, ammonia dermatitis refers to skin irritation caused by exposure to ammonia, acne is a common skin condition characterized by pimples, erythema is an abnormal redness of the skin, and hairiness refers to an excessive growth of hair on the skin.

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  • 7. 

    Abnormal hari dandruff, scabes, lice, ticks,

    • A.

      Option1

    • B.

      Option2

    • C.

      Option3

    • D.

      Option4

    Correct Answer
    A. Option1
    Explanation
    The given options are not visible, so it is not possible to provide an explanation without knowing the options.

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  • 8. 

    Capillary refill should be

    • A.

      Less than 3 seconds

    • B.

      Between 3 and 4 seconds

    • C.

      Greater than 4 seconds

    • D.

      Option 4

    Correct Answer
    A. Less than 3 seconds
    Explanation
    Capillary refill refers to the time it takes for the color to return to the skin after it has been pressed down and released. This is an important indicator of peripheral circulation and tissue perfusion. A capillary refill time of less than 3 seconds indicates good peripheral circulation and normal tissue perfusion. If the refill time is between 3 and 4 seconds, it may suggest compromised circulation or decreased tissue perfusion. A capillary refill time greater than 4 seconds is indicative of poor peripheral circulation and inadequate tissue perfusion. Therefore, the correct answer is less than 3 seconds.

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  • 9. 

    Therapeutic baths require a physcian's order.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Therapeutic baths require a physician's order because they are a medical treatment that involves specific instructions and considerations for the patient's condition. A physician's order ensures that the appropriate type of therapeutic bath is prescribed and that it is administered safely and effectively. Without a physician's order, there is a risk of using the wrong type of bath or causing harm to the patient. Therefore, it is necessary for a physician to assess the patient's condition and determine if a therapeutic bath is suitable and what specific instructions should be followed.

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  • 10. 

    What is detailed in therapeutic bath?

    • A.

      Type of bath

    • B.

      Temp of water

    • C.

      Body surface to be bathed

    • D.

      Option 4

    Correct Answer(s)
    A. Type of bath
    B. Temp of water
    C. Body surface to be bathed
    Explanation
    The question is asking about what is detailed in a therapeutic bath. The correct answer includes three components: the type of bath, the temperature of the water, and the body surface to be bathed. These details are important in determining the specific therapeutic benefits and effects of the bath.

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  • 11. 

    Types of baths include

    • A.

      Complete bed

    • B.

      Self-help

    • C.

      Partial

    • D.

      Bag

    • E.

      Tub

    • F.

      Sponge

    • G.

      Shower

    • H.

      Sprinkler

    Correct Answer(s)
    A. Complete bed
    B. Self-help
    C. Partial
    D. Bag
    E. Tub
    F. Sponge
    G. Shower
    Explanation
    The given answer lists different types of baths, including complete bed, self-help, partial, bag, tub, sponge, shower, and sprinkler. These are various methods or tools used for bathing. A complete bed bath involves washing the entire body of a person who is unable to bathe themselves. Self-help bath refers to a person bathing themselves with minimal assistance. A partial bath involves cleaning specific parts of the body. Bag baths are pre-moistened disposable washcloths used for bathing. Tub baths are taken in a bathtub, sponge baths involve using a sponge or washcloth to clean the body, and showers use running water to cleanse. The sprinkler bath may refer to a method of bathing using a sprinkler system.

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  • 12. 

    You can leave your patient unattended any time.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Only if they are completely safe.

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  • 13. 

    Diabetic patients require special foot care

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Diabetic patients require special foot care because they are at a higher risk for foot complications. Diabetes can lead to poor blood circulation and nerve damage in the feet, making them more susceptible to infections and injuries. Regular foot care, including daily washing, inspection for cuts or sores, proper nail trimming, and wearing appropriate footwear, can help prevent complications such as foot ulcers and amputation. Therefore, it is important for diabetic patients to prioritize special foot care.

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  • 14. 

    Discharge planning starts on admission

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Discharge planning refers to the process of planning and coordinating the transition of a patient from a healthcare facility to their home or another care setting. Starting discharge planning on admission allows healthcare professionals to assess the patient's needs, develop a comprehensive plan, and ensure a smooth and timely discharge. By initiating the process early, healthcare providers can address any potential barriers or challenges that may arise and ensure that the patient receives appropriate care and support after leaving the facility.

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  • 15. 

    Patients goals should be

    • A.

      Specific

    • B.

      Measuabble

    • C.

      Achievable

    • D.

      Realistic

    • E.

      Timeframe

    Correct Answer(s)
    A. Specific
    B. Measuabble
    C. Achievable
    D. Realistic
    E. Timeframe
    Explanation
    The correct answer is specific, measurable, achievable, realistic, and timeframe. These criteria are important for setting patient goals in healthcare. Specific goals provide clarity and focus, measurable goals allow for tracking progress, achievable goals ensure they are within reach, realistic goals consider the patient's abilities and resources, and timeframe sets a deadline for completion. By incorporating these elements, healthcare professionals can effectively guide patients towards successful outcomes.

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  • 16. 

    What is the number one nursing intervention?

    • A.

      Assess

    • B.

      Manage

    • C.

      Plan

    • D.

      Evaluate

    Correct Answer
    A. Assess
    Explanation
    Assessing is considered the number one nursing intervention because it is the initial step in the nursing process. By assessing, nurses gather relevant information about the patient's health status, including physical, emotional, and social factors. This information helps nurses identify potential health problems, establish priorities, and develop an individualized care plan. Without a thorough assessment, nurses may not have a comprehensive understanding of the patient's needs and may not be able to provide appropriate care. Therefore, assessing is crucial in providing effective and efficient nursing care.

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  • 17. 

    Three layers of skin, epidermis, dermis, subcutaneous tissue.

    • A.

      Option 1

    • B.

      Option 2

    • C.

      Option 3

    • D.

      Option 4

    Correct Answer
    A. Option 1
    Explanation
    The given answer is Option 1 because it correctly lists the three layers of the skin - epidermis, dermis, and subcutaneous tissue. The epidermis is the outermost layer of the skin, responsible for protecting the body from external factors. The dermis is the middle layer, containing blood vessels, nerves, and hair follicles. The subcutaneous tissue, also known as the hypodermis, is the innermost layer that provides insulation and stores fat.

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  • 18. 

    What does the skin do?

    • A.

      Regulate temp

    • B.

      Regulate fluids

    • C.

      Primary defense against pathogens

    • D.

      Makes me look good

    Correct Answer(s)
    A. Regulate temp
    B. Regulate fluids
    C. Primary defense against pathogens
    Explanation
    The skin performs multiple functions, including regulating body temperature, regulating fluids, and acting as the primary defense against pathogens. It helps maintain the body's internal temperature by sweating when it's hot and constricting blood vessels when it's cold. The skin also prevents excessive fluid loss and helps maintain the body's fluid balance. Additionally, it acts as a physical barrier, protecting the body from harmful bacteria, viruses, and other pathogens.

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  • 19. 

    • A.

      Option 1

    • B.

      Option 2

    • C.

      Option 3

    • D.

      Option 4

    Correct Answer
    A. Option 1
  • 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

    Correct Answer(s)
    A. Provides cushion over bony prominences
    C. Keeps me warm
    Explanation
    Adipose tissue serves multiple functions in the body. It acts as a cushion over bony prominences, providing protection and support. Additionally, it helps to regulate body temperature by insulating and keeping the body warm. While it is true that adipose tissue can contribute to a person's appearance of being fat, this is not its primary function. The statement about using adipose tissue to make candles is incorrect and unrelated to its actual purpose.

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  • 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

    Correct Answer
    A. Option 1
    Explanation
    The given statement suggests that bathing strips the skin of oil, which can restrict bathing. It also states that malnutrition causes the loss of subcutaneous tissue. Based on this information, Option 1, which likely discusses the importance of nutrition and hydration for maintaining healthy skin, is the correct answer.

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  • 22. 

    As we age the acid mantel is gone making the skin itchy.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    As we age, the acid mantle, which is a protective layer on the skin's surface, gradually diminishes. This can result in dryness and itchiness of the skin. Therefore, it is true that as we age, the acid mantle is gone, making the skin itchy.

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  • 23. 

    We assess skin turgor on elderly at the clavicle or forehead.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Skin turgor is a measure of the elasticity and hydration of the skin. It is commonly assessed in elderly individuals at the clavicle or forehead because these areas are less affected by age-related changes such as decreased elasticity and increased wrinkling. Assessing skin turgor at these locations provides a more accurate indication of hydration status in elderly individuals. Therefore, the statement that skin turgor is assessed on elderly at the clavicle or forehead is true.

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  • 24. 

    The three P's are pressure, pain and potty are assessed every 2 hours.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The statement is true because it states that the three P's (pressure, pain, and potty) are assessed every 2 hours. This implies that healthcare professionals regularly monitor and evaluate these three aspects in order to ensure the well-being and comfort of the patient. By assessing pressure, pain, and potty every 2 hours, healthcare providers can identify any issues or discomfort the patient may be experiencing and take appropriate actions to address them. This regular assessment helps in maintaining the patient's health and providing timely interventions if needed.

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  • 25. 

    We are we likely yo get pressure ulcers (bony prominences).

    • A.

      Sacrum

    • B.

      Occipitel

    • C.

      Scapula

    • D.

      Elbows

    • E.

      Heels

    Correct Answer(s)
    A. Sacrum
    B. Occipitel
    C. Scapula
    D. Elbows
    E. Heels
    Explanation
    Pressure ulcers, also known as bedsores, are more likely to occur on bony prominences due to the increased pressure and friction in those areas. Bony prominences, such as the sacrum, occiput, scapula, elbows, and heels, are areas where the bones are close to the skin's surface, making them more susceptible to pressure injuries. These areas are also commonly subjected to prolonged pressure when a person remains in one position for an extended period, leading to reduced blood flow and tissue damage. Therefore, it is important to regularly reposition individuals and provide adequate cushioning to prevent pressure ulcers from developing.

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  • 26. 

    Blood Pressure Category Systolic mm Hg (upper #)   Diastolic mm Hg (lower #) Normal less than 120 and less than 80 Prehypertension 120 – 139 or 80 – 89 High Blood Pressure (Hypertension) Stage 1 140 – 159 or 90 – 99 High Blood Pressure (Hypertension) Stage 2 160 or higher or 100 or higher Hypertensive Crisis (Emergency care needed) Higher than 180 or Higher than 110

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The given answer is true because it accurately reflects the information provided in the table. The table shows the different categories of blood pressure levels, with their corresponding systolic and diastolic values. The answer is true because it aligns with the information in the table, indicating that the statement is correct.

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  • 27. 

    Having a temperature below 100.4 is fine.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Having a temperature below 100.4 is considered fine because it falls within the normal range of body temperature. The average normal body temperature is typically around 98.6 degrees Fahrenheit or 37 degrees Celsius. However, it is important to note that individual body temperatures can vary slightly, and a temperature below 100.4 is still within the normal range and not considered a fever.

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  • 28. 

    Temperature becomes a problem when it spikes.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    When the temperature spikes, it means that there is a sudden and significant increase in temperature. This can be problematic because extreme temperatures can have negative effects on various aspects such as human health, infrastructure, and the environment. High temperatures can lead to heat-related illnesses, damage to buildings and roads, and can also contribute to climate change. Therefore, it is true that temperature becomes a problem when it spikes.

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  • 29. 

    Resting heart rate Age or fitness level Beats per minute (bpm) Babies to age 1: 100-160 Children ages 1 to 10: 70-120 Children ages 11 to 17: 60-100 Adults: 60-100 Well-conditioned athletes: 40-60

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The given answer is true because the resting heart rate can vary depending on factors such as age and fitness level. For babies up to age 1, a normal resting heart rate is between 100-160 beats per minute (bpm). For children ages 1 to 10, it is between 70-120 bpm. For children ages 11 to 17 and adults, a normal resting heart rate is between 60-100 bpm. Well-conditioned athletes may have a lower resting heart rate of 40-60 bpm due to their high level of fitness.

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  • 30. 

    What does PMI stand for

    • A.

      Point for maximum impulse.

    • B.

      Option 2

    • C.

      Option 3

    • D.

      Option 4

    Correct Answer
    A. Point for maximum impulse.
  • 31. 

    • birth to 6 weeks: 30–60 breaths per minute
    • 6 months: 25–40 breaths per minute
    • 3 years: 20–30 breaths per minute
    • 6 years: 18–25 breaths per minute
    • 10 years: 15–20 breaths per minute
    • adults: 12–20 breaths per minute

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The given answer is true because it accurately represents the normal range of breaths per minute for different age groups. The respiratory rate gradually decreases from birth to adulthood, with infants having the highest rate and adults having the lowest. This information is commonly used in medical settings to assess the respiratory health of individuals.

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  • 32. 

    Name the nine pulse sites.

    Correct Answer
    Temporal
    Carotid
    brachial
    radial
    apical
    femoral
    popliteal
    posterior tibeal
    dorsalis pedis
    Explanation
    The nine pulse sites are the locations on the body where a pulse can be felt. These include the temporal pulse (located on the side of the forehead), carotid pulse (located on the side of the neck), brachial pulse (located on the inner side of the upper arm), radial pulse (located on the wrist), apical pulse (located at the apex of the heart), femoral pulse (located in the groin), popliteal pulse (located behind the knee), posterior tibial pulse (located on the inner side of the ankle), and dorsalis pedis pulse (located on the top of the foot).

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  • 33. 

    What are the six cardinal views while testing gaze

    Correct Answer
    Right High
    Right low
    Right Middle
    Left Middle
    Left high
    Left low
    Explanation
    (1) straight nasal: medial rectus and the third cranial nerve; (2) up nasal: inferior oblique and the third cranial nerve; (3) down nasal: superior oblique and the fourth cranial nerve; (4) straight temporal: lateral rectus and the sixth cranial nerve; (5) up temporal: superior rectus and the third cranial nerve; and (6) down temporal: inferior rectus and the third cranial nerve. Also called extraocular movement

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  • 34. 

    The sclera will be either white or yellow.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The sclera, also known as the white of the eye, can vary in color from person to person. In most cases, the sclera is white, indicating a healthy eye. However, some individuals may have a yellowish tint to their sclera, which can be a sign of certain medical conditions such as jaundice or liver problems. Therefore, the statement that the sclera can be either white or yellow is true.

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  • 35. 

    Where are the lymph nodes?

    Correct Answer
    Occipital
    Parotid
    Submental
    Submandibular
    Supraclavicular
    Explanation
    The lymph nodes are located in various regions of the body, including the occipital, parotid, submental, submandibular, and supraclavicular areas. These lymph nodes are part of the lymphatic system, which plays a crucial role in the body's immune response. They help filter and trap foreign substances, such as bacteria or viruses, and produce immune cells to fight infections. The occipital lymph nodes are found at the back of the head, the parotid lymph nodes are located near the ears, the submental lymph nodes are under the chin, the submandibular lymph nodes are beneath the lower jaw, and the supraclavicular lymph nodes are above the collarbone.

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  • 36. 

    Ischemia causes pressure ulcers in as little as 2 hours.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Ischemia refers to a lack of blood supply to a particular area of the body. When there is inadequate blood flow, tissues can become deprived of oxygen and nutrients, leading to cell damage and death. In the case of pressure ulcers, prolonged pressure on a specific area of the body can restrict blood flow, causing ischemia. Without sufficient blood supply, the affected tissues are more susceptible to developing pressure ulcers, which can occur in as little as 2 hours. Therefore, the statement "Ischemia causes pressure ulcers in as little as 2 hours" is true.

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  • 37. 

    Turn, cough and deep breath every 2 hours (TCDP). use insentive sperometer 

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The statement is true because turning, coughing, and taking deep breaths every 2 hours is a common practice in medical settings to prevent complications such as pneumonia, atelectasis, and blood clots. Using an incentive spirometer is also recommended to help improve lung function and prevent respiratory complications. This routine helps to maintain lung expansion and prevent the buildup of secretions in the lungs, especially in patients who are bedridden or have limited mobility.

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  • 38. 

    What are the four stages of pressure ulcers

    Correct Answer
    Stage 1 Non blanchable reddened (erythema) area
    Stage 2 Partial thickness skin loss (epidermis) may have blistering
    Stage 3 Full thickness skin loss - damage or necrosis to skin up to the underlying facial
    Stage 4 Skin loss and necrosis with damage to muscle, bone and supporting structures (tendons and ligaments).
    Explanation
    The four stages of pressure ulcers are categorized based on the severity of the skin damage. Stage 1 refers to a non-blanchable reddened area, indicating the initial signs of skin damage. Stage 2 involves partial thickness skin loss, which may include blistering. In Stage 3, there is full thickness skin loss, with damage or necrosis extending to the underlying fascia. Finally, Stage 4 represents the most severe stage, with skin loss and necrosis, along with damage to muscle, bone, and supporting structures such as tendons and ligaments.

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  • 39. 

    What is an independent nursing intervention for stage 1 pressure ulcers

    Correct Answer
    Use a duoderm padded dressing and change every 7 days or when soiled.
    Explanation
    The independent nursing intervention for stage 1 pressure ulcers is to use a duoderm padded dressing and change it every 7 days or when soiled. This intervention helps to protect the pressure ulcer from further damage and promotes healing by providing a barrier between the ulcer and external factors. The duoderm dressing also helps to maintain a moist environment, which is beneficial for wound healing. Regular changing of the dressing ensures that the wound remains clean and free from infection.

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  • 40. 

    What is an unstagable pressure ulcer?

    Correct Answer
    An ulcer with escar (scab)
    Explanation
    An unstagable pressure ulcer refers to an ulcer that cannot be classified into any specific stage due to the presence of a scab or escar. The scab covers the base of the ulcer, making it difficult to determine the extent of tissue damage underneath. This type of ulcer requires further assessment and monitoring to determine the stage and appropriate treatment plan.

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  • 41. 

    A pressure ulcer retains it's stage even through the healing process.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Pressure ulcers, also known as bedsores, are categorized into different stages based on the severity of tissue damage. These stages range from Stage 1 (mild) to Stage 4 (severe). Once a pressure ulcer is classified into a specific stage, it retains that stage throughout the healing process. This means that even if the ulcer starts to heal and improve, it will still be considered as the same stage until it completely resolves. Therefore, the statement "A pressure ulcer retains its stage even through the healing process" is true.

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  • 42. 

    What are the assessment tools used to screen skin breakdown

    Correct Answer
    Braden scale
    Norton scale
    Explanation
    The Braden scale and Norton scale are both assessment tools used to screen for skin breakdown. The Braden scale is a widely used tool that assesses a patient's risk for developing pressure ulcers based on factors such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The Norton scale, on the other hand, is another commonly used tool that assesses a patient's risk for developing pressure ulcers based on factors such as physical condition, mental condition, activity, mobility, and incontinence. Both scales help healthcare professionals identify patients who are at risk for skin breakdown and implement appropriate preventive measures.

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  • 43. 

    Surgical dressing stay in place for 24-48 hrs.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Surgical dressings are designed to stay in place for a specific period of time after a surgical procedure. This allows the wound to heal properly and reduces the risk of infection. The recommended duration for surgical dressings to remain in place is usually 24-48 hours. During this time, the dressing provides protection to the wound, absorbs any discharge, and promotes healing. Therefore, the statement "Surgical dressing stay in place for 24-48 hrs" is true.

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  • 44. 

    Nurses can change the first surgical dressing.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Nurses cannot change the first surgical dressing.

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  • 45. 

    A clean surgical incision that heals without extra intervention is Primary Intention Healing.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Primary intention healing refers to the healing process of a clean surgical incision that closes without any complications. This type of healing occurs when the wound edges are closely approximated, allowing for direct healing with minimal scarring. It is characterized by the absence of infection, minimal tissue loss, and rapid healing. Therefore, the given statement is true.

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  • 46. 

    What are the types of surgical fluid drains or exudates from the wound?

    Correct Answer
    Purelant (stinky)
    Sanguinous (bloody fluid)
    Serous (clear)
    Serrosanguinous (both clear and bloody)
    Puroserrosanguanous (pus and blood)
    Explanation
    The types of surgical fluid drains or exudates from the wound include purelant (stinky), sanguinous (bloody fluid), serous (clear), serrosanguinous (both clear and bloody), and puroserrosanguanous (pus and blood). These different types of fluids can indicate the stage of wound healing and provide important information for healthcare professionals to monitor and treat the wound appropriately.

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  • 47. 

    How does the nurse test wether the incision will tolerate staple/suture removal?

    Correct Answer
    Start by removing or clipping every other staple/suture, assess and remove the rest if tolerated.
    Explanation
    The nurse tests whether the incision will tolerate staple/suture removal by starting with removing or clipping every other staple/suture. After this, the nurse assesses the incision to see if it is tolerating the removal well. If the incision is tolerating the removal, the nurse proceeds to remove the rest of the staples/sutures.

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  • 48. 

    Staples or sutures only by physician or by physician's order.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    This statement is true because the use of staples or sutures is a medical procedure that should only be performed by a physician or under a physician's order. These procedures require specialized knowledge and skills to ensure proper wound closure and minimize the risk of infection or complications. Therefore, it is important for only trained medical professionals to perform this task.

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  • 49. 

    Pressure ulcers only heal by secondary intention.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Pressure ulcers, also known as bedsores, are wounds that develop when pressure restricts blood flow to certain areas of the body. These wounds can be difficult to heal and often require a specific healing process called secondary intention. Secondary intention healing involves allowing the wound to heal naturally from the bottom up, without surgical intervention or closure. This process is necessary for pressure ulcers because they typically involve deep tissue damage and require the growth of new tissue from the wound bed. Therefore, the statement that pressure ulcers only heal by secondary intention is true.

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  • 50. 

    What is secondary intention healing?

    Correct Answer
    When a wound heals from the inside out. Typically an open or gapping wound healing.
    Explanation
    Secondary intention healing refers to the natural healing process of a wound where it heals from the inside out. This type of healing is usually seen in open or gapping wounds that cannot be closed by sutures or other means. In secondary intention healing, the wound gradually fills in with new tissue, starting from the bottom and progressing towards the surface. This process involves the formation of granulation tissue, contraction of the wound edges, and re-epithelialization. It may take a longer time compared to primary intention healing, where the wound edges are closed directly, but it is an effective method for healing large or contaminated wounds.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 20, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jan 14, 2014
    Quiz Created by
    Coachalan32309

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