Blood Pressure Exam 2

105 Questions | Total Attempts: 48

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Blood Pressure Exam 2

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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

  • 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

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