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Describe a closed bed.
Top linens are not folded back. The bed is ready for a new patient or resident. Closed beds are made for a new patient or resident. Closed beds are made for a resident who are up during the day.
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Explain how used linens are removed from the bed.
Remove used linens 1 piece at a time roll each piece away from you. The side that touched the person is inside the roll and away from you.
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____, ____, and ____ linens are changed right away.
Wet, damp, and soiled
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Always hold linens ____ from your uniform.
Away
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What is the purpose of the plastic drawsheet?
It is waterproof. Protect the bed if people are incontinent.
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An open bed is made for:
- Newly admitted persons arriving by wheelchair.
- Persons who are getting ready for bed.
- Persons who are out of bed for a short time.
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When making an occupied bed, cover the person with ____ before removing the top sheet.
bath blanket
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Surgical beds are made for persons:
- Returning to their rooms from surgery.
- Who arrive at the agency by ambulance.
- Who go by stretcher to treatment or therapy areas.
- Using portable tubs.
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What information do you need before making any bed?
- What type of bed to make – closed, open, occupied, or surgical.
- If you need to sue cotton drawsheet or a padded water proof drawsheet waterproof underpad incontinence product.
- If the person used bed rails.
- The person’s treatment therapy, and activity schedule.
- Position restriction or limits in the person’s movement or activity.
- How to position the person and the positioning device.
- If the bed needs to be locked into a certain position
- When to report observations.
- What patient or resident concerns to report at once.
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When you are finished making the bed, the wheels should be ____
Locked
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Oral hygiene reduces the risk for ______ and __________.
cavities and periodontal disease
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Which observations made during oral hygiene are reported to the nurse?
- Dry, cracked, swollen, or blistered lips.
- Mouth or breath odor.
- Redness, swelling, irritation, sourness, or white patches in the mouth or on the tongue.
- Bleeding, swelling, or redness of the gums.
- Loose teeth.
- Rough, sharp, or chipped areas on dentures.
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You are giving mouth care to an unconscious person. What should you use to keep the person’s mouth open?
Keep a padded tongue blade.
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How often is mouth care given to the unconscious person?
At least every 2 hours.
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You are cleaning a resident’s dentures. Explain how you will protect the dentures from breakage.
Never carry dentures in your hands. Always use a denture cup or kidney basin.
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Explain why hot water is not used to clean or store dentures.
Hot water caused dentures to lose their shape.
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To promote safety when giving a shower, you must turn _____ water on first, then ___ water. Turn ___ water off first, then ____ water.
cold water on first, then hot water. Turn hot water off first, then cold water.
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To safely apply powder, you need to:
- Turn away from the person.
- Sprinkle a small amount of power onto your hand or cloth.
- Apply the powder in a thin layer.
- Make sure powder does not get on the floor.
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A complete bed bath involves
Washing the person’s entire body in bed. (110 F and 115 F)
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Why might a towel bath be given to a person with dementia?
The towel bath is quick, soothing and relaxing.
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Before assisting a person with a tub bath or shower, what information do you need from the nurse and the care plan?
- What bath to give.
- How much help the person needs.
- The person’s activity or position limits.
- What water temperature to use what skin care products to use and what the person prefers.
- What observations to report and record.
- When to report observations.
- What patient or resident concerns to report at once.
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When giving perineal care, what safety measures are practiced?
- Measure water temperature.
- Protect yourself and the person from infection.
- Protect the person and dry garments and linens from wet or soiled items.
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Alopecia means _____.
hair loss
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_______ is infestation of the scalp with lice.
Pediculosis
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You assist persons with hair care. The nursing process reflects the person’s _____, ______, ______, _______, and _____.
culture, health history, personal choice, self-care skin, and scalp.
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Before brushing and combing hair, what information do you need from the nurse and the care plan?
- How much help the person needs.
- What to do for matted or tangled hair.
- What to do for curly, course, or dry hair.
- What hair care products to use.
- What observations to report and record.
- The person’s preferences and routine hair care measures.
- When to report observations.
- What patient or resident concerns to report at once.
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A resident’s hairbrush has sharp bristles. What should you do?
Reports concerns about the person’s brush or comb.
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You are shampooing a resident’s hair during her tub bath. How will you keep shampoo out of the person’s eyes?
Have the person hold a wash cloth over the eyes.
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Before shaving a person, what information do you need from the nurse and the care plan?
- What shaver to use - electric or safety.
- If the person takes anticoagulant drugs.
- When to shave the person.
- What facial hair to shave.
- If there are tender or sensitive areas on the person’s face.
- What observations to report and record.
- When to report observations.
- What patient or resident concerns to be report at once.
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A patient has diabetes. Which health team member cuts the person’s toenails?
The RN or podiatrist cuts toenails and provides food care for patients with diabetes.
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A patient has an IV in his left arm. You are changing the person’s gown. The gown is removed from the ____ arm first.
no IV
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Remove clothing from the ____ side first. Apply clothing to the weak side first.
strong, weak
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The introduction of fluid into the rectum and lower colon
Enema
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A surgically created opening between the ileum and the abdominal wall
Ileostomy
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Gas or air passed through the anus
Flatus
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A surgically created opening between the colon and the abdominal wall
Colostomy
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The frequent passage of liquid stools
Diarrhea
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The alternating contraction and relaxation of intestinal muscles
Peristalsis
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The prolonged retention and buildup of feces in the rectum
Fecal impaction
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The inability to control the passage of feces and gas through the anus
Fecal incontinence
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The passage of a hard, dry stool
Constipation
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The excessive formation of gas or air in the stomach and intestines
Flatulence
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A cone-shaped, solid drug that is inserted into a body opening
Suppository
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Bleeding in the stomach and small intestine causes ____ or ____ stools.
black or tarry
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Describe the role of diet in preventing constipation.
High fiber foods leave a residue for needed bulk to prevent constipation. Milk and milk products can cause constipation. Plenty of fluids.
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How does fluid intake affect bowel elimination?
Feces harden and dry when large amounts of water are absorbed or from poor fluid intake.
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A resident has diarrhea. You need to:
- Assist with elimination needs promptly.
- Dispose of stools promptly.
- Give good skin care.
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The person with fecal incontinence may need the following care measures:
- Bowel training.
- Help with elimination after meals and every 2 to 3 hours.
- Incontinent product to keep gourmet and linens cleans.
- Give good skin care.
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If flatus is not expelled, the intestines distend. List four measures that often reduce flatus.
- Exercise.
- Walking.
- Moving in bed.
- Left side-lying position.
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_____ stools drain constantly from an ileostomy.
Liquid
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The person with an ostomy can wear normal clothing. Why are tight garments avoided?
Tight garments can prevent feces from entering the pouch.
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Unless otherwise ordered, take vital signs with the person at ____.
rest
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What should you do if you are unsure of any vital sign measurement?
Ask the nurse to take them again.
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Body temperature is the balance between
The amount of heat produced and the amount lost by the body.
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Glass thermometers have the following problems:
- They take long time to register 3 to 10 minutes.
- They break easily
- The person may bite down and break oral thermometer.
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You should not use hot water to clean a glass thermometer because ______.
it could break
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Rectal temperatures are not taken if the person:
- Has diarrhea.
- Has a rectal disorder or injury.
- Has heart disease.
- Had rectal surgery.
- Is confused or agitate.
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The nurse asks you to take a resident’s temperature. How should you hold the adult’s ear?
The ear is pulled up and back.
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What special measures are needed when taking a temperature using the axillary site?
Make sure axilla is dry. Do not use the site right after bathing leave the thermometer in place for 5 to 10 minutes.
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The ____ pulse is used for routine vital signs.
radial
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A ______ is an instrument used to listen to sounds produced by the heart, lungs, and other body organs.
stethoscope
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Which pulse is taken with a stethoscope?
Apical pulse
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An irregular pulse occurs when the beats are not evenly special or beats are skipped.
the beats are not evenly special or beats are skipped
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Hard-to-feel pulses are described as __________________
weak, thready,or feeble PMI (Point of Maximal)
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How long should you count an apical pulse?
1 minute
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Each respiration involves
the chest rising and falling.
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When counting respiration, observe, report, and record the following:
- Respiratory rate.
- Equality and depth of respiration.
- If the respirations here regular or irregular.
- If the person has pain or difficulty breathing.
- Any respiratory noises.
- An abnormal respiratory pattern.
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What is the normal respiratory rate for newborns?
35 respirations per minute.
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The systolic pressure is __________
the period of heat muscles contraction
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You must report any systolic pressure at or above __________ and any diastolic pressure at or above ______.
120 mm Hg and 80 mm Hg
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Hypotension is
systolic pressure is 140 mm HG or lower or the diastolic pressure is 90 mm Hg or lower.
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List two complications of bedrest affecting the gastrointestinal system.
- Pressure ulcers
- Constipation
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A contracture is ______________________. The contracted muscle is __________________.
- the lack of joint mobility caused by abnormal shortening of a muscle.
- fixed into piston, is deformed, and cannot stretch.
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______ is a decrease in size or wasting away of muscle.
Atrophy
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What is the purpose of a hip abduction wedge?
Keep the hips abducted. The wedge is placed between the person’s legs.
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Hand rolls and hand grips prevent contractures of the _____, _______, and _______.
thumb, fingers, and wrist
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Why are bed cradles used?
Keeps the height of top lines off the feet and toes.
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The movement of a joint to the extent possible without causing pain is
Range of Motion (ROM)
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Bending a body part
Flexion
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Turning the joint upward
Supination
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Bending the foot down at the ankle
Plantar
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Turning the joint inward
Internal rotation
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Moving a body part away from the mid-line of the body
Abduction
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You have performed active-assistive range-of-motion exercises to a person’s knees. What information do you need to report and record?
- Time the exercise were performed.
- The number of times the exercise were performed.
- Complaints of pain or signs of stiffness or spasm.
- The degree to which the person took part in the exercises.
- When to report observations.
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List and describe the range-of-motion exercises performed to the forearm.
- Pronation – turn the hand so the pals is down.
- Supination – turn the hand so the palm is up.
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Before helping the person with ambulation, what information do you need from the nurse and the care plan?
- How much help the person needs.
- If the person uses a cane, walker, crutches, or an orthotic device.
- Areas of weakness.
- How far to walk the person.
- What observations to report and record.
- When to report observations.
- What patient or resident concerns to report at once.
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When are crutches used?
When the person cannot use 1 leg or when 1 or both legs needs to gain strength.
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A cane is held on the ____ side of the body.
strong
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_____ support weak body parts, prevent or correct deformities, or prevent joint movement.
Orthotic device
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OBRA requires activity programs for nursing center residents. A good activity program improves __________.
physical and mental well being.
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