Foundations UNMEB 2019 DNE - Nurses Revision

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Diploma in Nursing · 2019

Foundations DNE 11 2019 UNMEB Revision Guide

SECTION A: Objective Questions (20 marks)

💡 Exam Strategy: Focus on prioritization and safety! Many questions test what you should do FIRST or what is MOST important in nursing practice.

1 Which of the following laws regulates nursing practice?

a) Common law
b) Statutory law
c) Civil law
d) Criminal law

(b) Statutory law

Statutory law is created by legislative bodies (parliament) and includes the Nurses and Midwives Act, Council regulations, and practice standards. These laws specifically define nursing scope of practice, licensure requirements, professional standards, and disciplinary procedures. In Uganda, the Nurses and Midwives Act Cap 274 is the primary statutory law governing nursing.

(a) Common law: Judge-made law based on precedent; influences malpractice but does not directly regulate professional practice like statutory law.
(c) Civil law: Deals with disputes between individuals; used in malpractice lawsuits but not primary regulatory mechanism.
(d) Criminal law: Addresses crimes against society; only relevant when nurses commit criminal acts, not day-to-day practice regulation.

LAW TYPES: “STAT-CAN-CI-CRIM” – Statutory = Standards, Common = Cases, Civil = Compensation, Criminal = Crimes

2 The subjective data that can be noted on assessing a post-operative patient is

a) Vital signs
b) Laboratory test results
c) Patient’s description of pain
d) Observable facial expression

Subjective data is information reported by the patient that cannot be directly observed or measured. The patient’s verbal description of their pain (quality, intensity, location) is classic subjective data. Vital signs, lab results, and facial expressions are objective data that can be measured or observed by the nurse.

(a) Vital signs: Objective, measurable data (numbers from equipment like BP cuff, thermometer).
(b) Laboratory results: Objective data from scientific measurement of blood/urine samples.
(d) Observable facial expression: Objective data that nurse can see and document (e.g., grimacing).

🗣️ Subjective vs Objective: If the patient SAID it, it’s subjective. If you SAW it or MEASURED it, it’s objective. Pain is ALWAYS subjective!

3 Which of the following is the most appropriate, initial action of a nurse who is assessing a patient on traction?

a) Conduct thorough observation of the extremities
b) Ensure weights are hanging freely
c) Ascertain that cords and pulleys are running freely
d) Confirm that pin punctures are dry and clean

(b) Ensure weights are hanging freely

Safety and effectiveness of traction depends on continuous, uninterrupted weight application. Checking that weights hang freely must be done first because any interference (weights touching floor, bed, or furniture) makes traction ineffective and can cause patient injury. This is a quick, life-safety check before detailed assessment.

(a) Observe extremities: Important for neurovascular assessment but not the first priority. Should be done after confirming traction apparatus is functional.
(c) Check cords and pulleys: Also important but secondary to weight check; weights hanging freely implies system is working.
(d) Check pin sites: Critical for infection prevention but not the immediate first action on entering room.

TRACTION SAFETY: “WEIGHTS-CORDS-PINS” – Weights free, Cords clear, Pulleys smooth, Pins clean, Neurovascular checks last

4 Which of the following types of traction is used to manage fractures in children under five years?

a) Pulp
b) Gallows
c) Skeletal
d) Fixed balance

(b) Gallows

Gallows traction (also called Bryant’s traction) is used for femoral shaft fractures in children under 2 years (sometimes up to 3 years). The child lies supine with both legs flexed 90° at hips and knees, traction applied via skin tapes to both legs, and the buttocks are slightly elevated off the bed. This position allows gravity to provide counter-traction using the child’s body weight. The name comes from the slight resemblance to a gallows frame.

(a) Pulp traction: Not a recognized type of traction; does not exist in orthopaedic practice.
(c) Skeletal traction: Used in older children and adults; involves pins/screws through bone and is too invasive for toddlers.
(d) Fixed balance: Not a standard traction type; may refer to fixed traction but not specific to pediatric fractures.

👶 Age Matters: Gallows/Bryant’s traction: <2 years, Russell traction: 3-10 years, Skeletal traction:>10 years

5 Which of the following is an indication for gastrostomy feeding?

a) Unconscious patient
b) Oesophageal atresia
c) Fractured jaw
d) Gastroenteritis

(b) Oesophageal atresia

Oesophageal atresia is a congenital anomaly where the esophagus ends in a blind pouch, preventing normal swallowing and nutrition. A gastrostomy tube (G-tube) is placed directly into the stomach to provide long-term feeding access until surgical repair can be performed. This is a definitive indication for gastrostomy, whereas other options may be managed with less invasive methods.

(a) Unconscious patient: Can usually be fed via nasogastric (NG) tube; gastrostomy is invasive and reserved for prolonged unconsciousness (>4 weeks).
(c) Fractured jaw: Temporary liquid diet or NG feeding is sufficient; gastrostomy is not first-line.
(d) Gastroenteritis:Contraindicated as GI tract needs rest; IV fluids are preferred for severe cases.

GASTROSTOMY INDICATIONS: “O-STOP” – Obstruction (esophageal), Swallowing disorders, Trauma, Oral/head/neck cancer, Prolonged ventilation

6 The most correct nursing action before administering drugs to a patient is to

a) Collect drug from the pharmacy
b) Document the drug
c) Identify correct drug
d) Write prescription in the chart

The first step in medication administration is verifying the “Right Drug” – one of the 5 Rights of medication safety. This involves checking the medication label against the prescription three times: when removing from storage, when preparing, and before administering. This prevents medication errors which are a leading cause of patient harm. Cannot proceed safely without confirming correct drug identity.

(a) Collect from pharmacy:Logistical step that occurs before medication preparation, not the immediate action before administration.
(b) Document the drug:Occurs AFTER administration; documenting before giving drug is premature and unsafe.
(d) Write prescription:Physician’s responsibility, not nurse’s action. Nurses cannot prescribe (except advanced practice).

⚠️ 5 Rights + 2 More: Right patient, drug, dose, route, time + Right documentation, Right reason. ALWAYS verify drug identity first!

7 The appropriate action a nurse should undertake if the site of IV infusion is swollen and appears tender is to

a) Massage the area
b) Flush the canula with sterile water
c) Reduce the flow and inform the in charge
d) Stop the infusion at once

(d) Stop the infusion at once

Swelling and tenderness indicate infiltration (fluid leaking into tissues) or phlebitis (vein inflammation). Immediate action is to STOP the infusion to prevent further tissue damage. Continuing any fluid administration—even slowly—worsens edema, pain, and risk of tissue necrosis (especially with vesicant drugs). This is a safety priority before any other assessment or intervention.

(a) Massage the area:Contraindicated – increases tissue damage and spreads infiltrated medication.
(b) Flush the canula:Dangerous – forces more fluid into already compromised tissue, worsening injury.
(c) Reduce flow and inform:Inadequate response; any continued infusion causes harm. Must STOP completely first.

INFILTRATION RESPONSE: “STOP-SITE-SAVE” – Stop infusion, Remove cannula, Assess, Document, Elevate, Warm/cold compress

8 Which of the following is an action in the planning phase of the nursing process?

a) Documenting data
b) Analyzing data
c) Establishing expected outcomes
d) Selecting patient’s concerns

The Planning phase of the nursing process involves setting goals and expected outcomes derived from nursing diagnoses. Outcomes are specific, measurable statements of what the patient will achieve. This follows the Assessment and Diagnosis phases and precedes Implementation. It provides direction for interventions and criteria for evaluation.

(a) Documenting data: Occurs during Assessment phase (and throughout), not specifically planning.
(b) Analyzing data: Part of Diagnosis phase where nurse identifies patterns and makes nursing diagnoses.
(d) Selecting patient’s concerns: Part of Diagnosis phase – identifying which nursing diagnoses to prioritize.

NURSING PROCESS: “ADPIE” – Assessment, Diagnosis, Planning, Implementation, Evaluation. Planning = Goals & Outcomes!

9 A common cause of patient’s discomfort during nursing care is

a) Restricted movement
b) Rest and sleep
c) Passive exercises
d) Body pain

(a) Restricted movement

Immobility and restricted movement cause multiple discomforts: muscle stiffness, joint contractures, pressure ulcers, venous stasis, constipation, urinary stasis, and psychological distress. These physiological effects create significant patient discomfort across multiple body systems. While pain is also discomfort, restricted movement is a more pervasive cause affecting overall well-being.

(b) Rest and sleep:Promote comfort and healing, not cause discomfort (though poor quality sleep can).
(c) Passive exercises: Actually prevent discomfort from stiffness and improve circulation when done correctly.
(d) Body pain: Is discomfort itself, not a cause of discomfort in this context; it’s the symptom.

🛏️ Immobility Complications: Pressure ulcers (5 days), DVT (7 days), Muscle atrophy (2 weeks), Contractures (4 weeks), Osteoporosis (6 weeks)

10 Which of the following is an example of a nursing diagnosis?

a) Effective coping mechanism
b) Activity intolerance
c) Loss of appetite
d) Failure to sleep

(b) Activity intolerance

Activity intolerance is an official NANDA-I nursing diagnosis defined as “insufficient physiological or psychological energy to endure or complete required or desired daily activities.” Nursing diagnoses are standardized clinical judgments about human responses to health conditions that nurses can treat independently. They follow PES format (Problem, Etiology, Symptoms).

(a) Effective coping mechanism: This is a strength/positive outcome, not a nursing diagnosis (though “Ineffective coping” is).
(c) Loss of appetite: A medical symptom/sign, not a nursing diagnosis. “Imbalanced nutrition: less than body requirements” would be the actual diagnosis.
(d) Failure to sleep: A symptom; the nursing diagnosis would be “Disturbed sleep pattern” or “Insomnia.”

NANDA DIAGNOSES: 13 domains including Nutrition, Elimination, Activity/Rest, Perception/Cognition, Coping/Stress, Life Principles

11 Which of the following is an indication for an eye cold compress?

a) Relieve pain
b) Relieve swelling
c) Reduce intraocular pressure
d) Remove discharge

(b) Relieve swelling

Cold compress causes vasoconstriction, reducing blood flow to the area and thereby decreasing edema (swelling) and inflammation. This is the primary indication for periorbital trauma, allergic reactions, or post-operative edema. Cold also provides analgesic effect by reducing nerve conduction velocity.

(a) Relieve pain:Secondary benefit of cold therapy, but swelling reduction is primary indication.
(c) Reduce intraocular pressure: Cold compress does not significantly affect IOP. Medications (beta-blockers, prostaglandins) are used for glaucoma.
(d) Remove discharge: Warm compresses are better for softening and loosening crusts/discharge. Cold would harden secretions.

🧊 Cold vs Warm: Cold = acute injury (<24-48 hrs), swelling, inflammation. Warm=chronic pain, stiffness, discharge removal, abscess localization

12 Which of the following solutions is recommended for cleaning tracheostomy tubes?

a) Salvon
b) Sodium bicarbonate
c) Normal saline
d) Hibitane

Normal saline (0.9% NaCl) is isotonic and non-irritating to respiratory mucosa, making it safe for cleaning inner cannulas and suctioning. It doesn’t cause chemical irritation or ciliary damage. Sterile technique is essential to prevent hospital-acquired pneumonia. Clean inner cannula every 4-8 hours or when soiled.

(a) Salvon: Chlorhexidine-based antiseptic; toxic if inhaled and can cause chemical pneumonitis.
(b) Sodium bicarbonate: Alkaline solution that can damage respiratory cilia and mucosa, altering pH.
(d) Hibitane: Chlorhexidine gluconate; contraindicated in respiratory tract due to toxicity risk.

⚠️ Respiratory Safety: ONLY use sterile normal saline for anything entering airway! Antiseptics are TOXIC to lungs!

13 Which of the following solutions is recommended for cleaning the area around a colostomy?

a) Alcohol
b) Soapy water
c) Iodine
d) Sodium bicarbonate

(b) Soapy water

Soapy water (mild soap and warm water) is recommended for cleaning peristomal skin. It’s gentle, non-irritating, and effectively removes fecal residue without damaging skin. Alcohol and iodine are too harsh and can cause dermatitis. Sodium bicarbonate is alkaline and disrupts skin pH. Clean from stoma outward in circular motions, rinse thoroughly, pat dry completely before applying new pouch.

(a) Alcohol:Too drying and irritating, causes skin breakdown and stinging on application.
(c) Iodine:Allergic reactions common, stains skin, disrupts normal flora.
(d) Sodium bicarbonate:Alkaline pH damages skin barrier, no cleansing properties.

🧼 Peristomal Care: Use only mild soap! No alcohol, iodine, or harsh antiseptics. Skin must be completely dry before pouch application to ensure adhesion.

14 Which statement is true when performing an abdominal paracentesis?

a) Place patient in sitting up position
b) It is not necessary to obtain consent
c) Support abdomen with saline soaked gauze
d) Hold drainage tube and inflate

Copy

(a) Place patient in sitting up position

Semi-sitting or upright position (45-90°) is the correct position for abdominal paracentesis. This allows fluid to accumulate in dependent portions of abdomen, making it easier to locate and drain. It also increases patient comfort and reduces risk of vasovagal reaction. Position is maintained throughout procedure. Supine position makes fluid distribution diffuse and increases risk of bowel perforation.

(b) No consent needed:FALSE! Paracentesis is invasive; informed consent is mandatory (except emergencies).
(c) Saline soaked gauze:Not used during procedure; may be used after to clean site but not to support abdomen.
(d) Hold tube and inflate:Incorrect technique; tube is inserted and fluid drains by gravity/suction, no inflation needed.

PARACENTESIS POSITION: “SIT-UP-STRAIGHT” – Sitting Up allows Safe Tap, Reduces Injury, Aids Gravity, Improves Target

15 Which of the following findings on assessment of an operation site is normal?

a) Red, hard skin
b) Warm, tender skin
c) Purulent discharge
d) Serous discharge

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(d) Serous discharge

Serous discharge (clear, watery, thin fluid) is normal in first 24-48 hours post-op. It’s part of inflammatory response as wound begins to heal. Small amounts of serous drainage on dressing are expected. Contrast with purulent (infection), sanguineous (bleeding), or serosanguinous (mix of serum and blood) which may indicate complications. Wound should be clean, dry, and approximated with mild erythema only.

(a) Red, hard skin: Indicates cellulitis or infection; erythema should be mild and localized.
(b) Warm, tender skin:Inflammation/infection signs; normal wound is not warm or tender after 24-48 hrs.
(c) Purulent discharge:Definitive sign of infection – thick, yellow/green, foul-smelling. Requires culture and antibiotics.

🔍 Wound Assessment Timeline: Day 1-2: Serous OK. Day 3-5: Should be dry. After Day 5: Any drainage = investigate for dehiscence/infection!

16 Which of the following is the primary reason for using nursing care plans?

a) Ensure consistency for care
b) Identify client’s problems
c) Provide justification for care
d) Utilize critical thinking skills

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(a) Ensure consistency for care

The primary purpose of nursing care plans is to ensure consistent, coordinated care across all shifts and caregivers. It communicates patient needs, planned interventions, and expected outcomes to the entire healthcare team. Without a care plan, each nurse might provide different care, leading to fragmentation and errors. While other options are benefits, consistency is the fundamental reason care plans exist.

(b) Identify problems: This occurs during assessment and diagnosis phase, before care plan is written.
(c) Justify care:Legal benefit but not primary purpose; documentation serves this purpose.
(d) Utilize critical thinking:Process benefit but not the end goal. The goal is standardized care delivery.

CARE PLAN PURPOSE: “C-C-C-C-C” – Communicate, Coordinate, Consistency, Continuity, Collaborate

17 The main use of a trapeze for a patient on traction is to

a) Lift the weight of the linen off bed
b) Elevate the foot of the bed
c) Prop-up the patient in bed
d) Lift patient off bed

Copy

A trapeze (triangular bar suspended overhead) allows patients on traction to lift their own torso using arm strength to reposition, transfer to bedpan, perform hygiene, and prevent muscle atrophy. It promotes independence and reduces risk of complications from immobility. The patient pulls up on the trapeze to raise chest/shoulders off bed while maintaining traction alignment.

(a) Lift linen:Not its purpose; linen can be managed with bed cradles or by staff.
(b) Elevate foot of bed:Tilt table or Trendelenburg positions do this, not trapeze.
(d) Lift patient off bed:Too dangerous; patient cannot support full weight while in traction. Mechanical lift is needed for transfers.

💪 Trapeze Benefits: Increases independence, maintains upper body strength, reduces nurses’ back strain, prevents aspiration during eating (can sit up), improves lung expansion (reduces pneumonia risk)!

18 Which of the following is NOT an indication of under-water seal drainage?

a) Empyema
b) Pneumothorax
c) Ascites
d) Haemothorax

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Under-water seal drainage (chest drain) is used for conditions in pleural space, NOT peritoneal cavity. Ascites is fluid accumulation in peritoneal cavity and is treated with paracentesis (needle aspiration) or peritoneal drain, not chest tube. Under-water seal creates one-way valve allowing air/fluid to exit pleural space but not re-enter, essential for lung re-expansion.

(a) Empyema: IS indication – pus in pleural space requires drainage.
(b) Pneumothorax: IS indication – air in pleural space prevents lung collapse; chest drain removes air.
(d) Haemothorax: IS indication – blood in pleural space from trauma needs drainage.

CHEST DRAIN INDICATIONS: “PE-HEM-PNEU” – Pleural effusion, Empyema, Hemothorax, Pneumothorax, Post-op thoracotomy

19 The rationale for placing a patient in a flexed position for lumbar puncture is to

a) Increase the flow of CSF
b) Increase the inter-vertebral space
c) Prevent risks of trauma
d) Reduce patient’s anxiety

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(b) Increase the inter-vertebral space

Flexed (fetal) position with knees drawn to chest and chin to knees maximally widens the intervertebral spaces, especially between L3-L4 or L4-L5 (common LP sites). This position separates the spinous processes, making needle insertion easier and reducing risk of bony contact/trauma. It also reduces lumbar lordosis.

(a) Increase CSF flow:Not primary reason; CSF flow is constant at ~20 drops/min regardless of position.
(c) Prevent trauma:Indirect benefit of wider space, but “increase space” is the direct physiological rationale.
(d) Reduce anxiety:Not true; flexed position can increase anxiety and is uncomfortable, but necessary for procedure.

🎯 LP Positioning: Lateral recumbent with MAXIMAL flexion is key! Measure opening pressure with patient level. Bedside ultrasound can help guide needle placement in difficult cases.

20 Which of the following is NOT an orthopaedic splint?

a) Brown’s
b) Thomas
c) Gallow’s
d) Plaster of paris

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Gallow’s is a type of TRACTION used for femoral fractures in young children, not a splint. Splints are rigid or semi-rigid devices for immobilization. Brown’s splint (humerus), Thomas splint (femur/tibia), and Plaster of Paris casts are all orthopaedic splints. Gallow’s (Bryant’s) traction uses skin traction on both legs with hips/knees flexed 90°.

(a) Brown’s splint: IS a splint – humeral fracture splint, side bars with axillary pad.
(b) Thomas splint: IS a splint – ring splint for femoral shaft fractures, half-ring at groin with side bars.
(d) Plaster of Paris: IS a splint – casting material that hardens to immobilize fractures.

TRACTION vs SPLINT: Traction pulls (Gallow’s, Russell), Splint immobilizes (Thomas, Brown, Plaster)

SECTION B: Fill in the Blank Spaces (10 marks)

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21 A type of tracheostomy tube with both the outer and inner tube and an obturator is called………………………

Double-lumen or fenestrated tracheostomy tube

A double-lumen tracheostomy tube consists of an outer cannula (main tube), inner cannula (removable liner), and an obturator (smooth guide for insertion). The inner cannula can be removed for cleaning without changing the entire tube. Some have fenestrations (holes) to allow air passage through vocal cords for speech. Obturator is removed after tube placement to allow airflow.

22 A surgical procedure in which the colon is shortened to remove damaged parts and an opening diverted in the abdominal wall is called………………………

Colostomy formation (or bowel/colon resection with colostomy)

This describes a Hartmann’s procedure or similar where diseased colon segment is resected and proximal end brought out as colostomy. Common for colorectal cancer, perforated diverticulitis, trauma. Can be temporary or permanent. Involves creating stoma from colon to divert fecal flow, allowing distal bowel to heal.

23 Removal of excess fluid from the abdominal cavity is called………………………

Paracentesis (or abdominal paracentesis)

Paracentesis is needle drainage of peritoneal fluid (ascites). Used for diagnostic sampling or therapeutic removal (large volume paracentesis). Common in liver cirrhosis, malignancy, heart failure. Requires sterile technique, ultrasound guidance preferred. Monitor for hypotension from fluid shift, replace albumin if >5L removed.

24 The creation of an artificial external opening into the stomach for gastric decompression is called………………………

Gastrostomy (or percutaneous endoscopic gastrostomy – PEG)

Gastrostomy creates direct access to stomach through abdominal wall. Indications: long-term feeding (>4 weeks), gastric decompression in obstruction. Can be surgical or endoscopic (PEG tube). Complications: peristomal infection, tube displacement, peritonitis if dislodged within 2 weeks of placement. Requires meticulous site care.

25 Wash out of the stomach contents through a stomach tube is known as………………………

Gastric lavage

Gastric lavage involves inserting large-bore orogastric tube and irrigating stomach with normal saline to remove toxins, blood, or ingested poisons. Used within 1 hour of ingestion (questionable benefit after). Risk: aspiration, esophageal perforation. Largely replaced by activated charcoal. Contraindicated in corrosive ingestion, coma without airway protection.

26 An artificial permanent opening between the ileum and the colon is called………………………

Ileocolic anastomosis (or ileostomy if to abdominal wall)

If internal opening between ileum and colon: ileocolic anastomosis (surgical connection after resection). If to abdominal wall: ileostomy (brings ileum to surface). Ileostomy produces liquid, enzyme-rich output that is corrosive to skin. Requires convex pouching system and skin barrier paste. Common in Crohn’s disease, ulcerative colitis.

27 An introduction of a solution through the stoma to wash out the bowel is termed as………………………

Colostomy irrigation (or stoma irrigation)

Colostomy irrigation is instilling warm water into colostomy to stimulate evacuation and regulate bowel function. Used for sigmoid colostomies to achieve bowel control and avoid pouching. Patient performs daily/bid to achieve predictable emptying. Contraindicated in ascending/transverse colostomies, chemotherapy, radiation, diverticulitis. Requires training and specialized equipment.

28 A procedure of inserting a needle into the subarachnoid space to access cerebral spinal fluid is called………………………

Lumbar puncture (or spinal tap)

Lumbar puncture obtains CSF from L3-L4 or L4-L5 interspace for diagnostic testing (infection, hemorrhage, pressure measurement) or therapeutic purposes (spinal anesthesia, intrathecal medication). Risks: post-dural puncture headache (PDPH), infection, herniation if high ICP. Patient flexed in lateral decubitus. Measure opening pressure with manometer.

29 The 3rd step of bone healing is known as………………………

Callus formation (or hard callus formation)

Bone healing 4 stages: 1) Hematoma formation (immediately), 2) Inflammatory phase (1-7 days), 3) Callus formation (2-6 weeks) – fibrocartilaginous and bony callus bridges fracture, visible on X-ray, 4) Remodeling (months-years) – woven bone replaced by lamellar bone. Callus formation is critical transition where fracture becomes stable enough for mobilization.

30 Inflammation of the bone due to pathogenic infection is called ………………………

Osteomyelitis

Osteomyelitis is infection of bone and marrow, usually bacterial (Staph aureus). Routes: hematogenous (children), direct inoculation (trauma, surgery), contiguous spread (diabetic foot). Signs: fever, localized pain, swelling, erythema. Chronic: draining sinus tracts, sequestrum (dead bone), involucrum (new bone sheath). Treatment: long-term IV antibiotics (4-6 weeks), surgical debridement. Risk of sepsis and amputation.

SECTION B: Short Essay Questions (10 marks)

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31 List ten (10) signs and symptoms a nurse should instruct the patient to report immediately after abdominal paracentesis. (5 marks)

Post-paracentesis complications require immediate reporting:

1. Sudden dizziness or fainting: Indicates vasovagal reaction or hypotension from rapid fluid shift.

2. Severe abdominal pain or worsening pain: May indicate bowel perforation, bleeding, or peritonitis.

3. Fever >38°C or chills: Sign of infection (peritonitis, bacteremia) requiring urgent antibiotics.

4. Hypotension or feeling lightheaded: Large volume removal causes fluid shifts, third spacing, and circulatory collapse.

5. Tachycardia or palpitations: Compensatory response to hypotension or early sign of sepsis.

6. Bleeding or hematoma at puncture site: May indicate vessel injury or coagulopathy.

7. Increasing abdominal distension: Sugg recurrence of ascites or internal bleeding.

8. Nausea and vomiting: May indicate peritoneal irritation, infection, or hypotension.

9. Decreased urine output: Suggests hypovolemia and renal hypoperfusion; risk of hepatorenal syndrome.

10. Redness, warmth, swelling at site: Local signs of infection or cellulitis.

POST-PARACENTESIS RED FLAGS: “F-PAINS-FEVER” – Fainting, Pain, Ascites return, Infection signs, No urine, Site bleeding, Fever, Erythema, Redness

32 Outline five (5) best motor responses you would check for during a neurological assessment. (5 marks)

Using Glasgow Coma Scale motor component:

1. Obeys commands: “Lift your arm,” “Show me two fingers” – patient performs purposeful movements on command (Score 6).

2. Localizes to painful stimulus: When supraorbital pressure or nail bed pressure applied, patient reaches toward and attempts to remove stimulus (Score 5).

3. Withdraws from pain: Flexes elbow and pulls away from painful stimulus (normal flexion withdrawal) but does not localize (Score 4).

4. Decorticate posturing: Abnormal flexion – arms flex to chest, fists clenched, legs extended. Indicates lesion above midbrain (Score 3).

5. Decerebrate posturing: Abnormal extension – arms extended, forearms pronated, wrists flexed, legs extended. Indicates midbrain/pons lesion (Score 2).

6. No motor response: Flaccid, no movement to any stimulus (Score 1). Indicates severe brainstem injury.

🧠 GCS Motor Score: 6=Obeys, 5=Localizes, 4=Withdraws, 3=Decorticate, 2=Decerebrate, 1=None. Decorticate = “good” flexion, Decerebrate = “bad” extension. Lower score = worse prognosis!

SECTION C: Long Essay Questions (50 marks)

33 (a) Outline five (5) indications of orthopaedic splints. (5 marks)
(b) Describe the procedure of skin traction. (15 marks)

(a) Indications for Orthopaedic Splints:

1. Immobilization of fractures: Maintain alignment of broken bones, prevent displacement, and provide stabilization before definitive casting or surgery.

2. Soft tissue injuries: Support sprains, strains, and ligament injuries to reduce pain and swelling while allowing some swelling accommodation.

3. Post-operative protection: Protect surgical sites after internal fixation or tendon repair while allowing wound inspection.

4. Temporary stabilization: Emergency use in pre-hospital setting or while awaiting definitive treatment.

5. Joint contracture prevention: Maintain functional position in neurologic conditions or prolonged immobilization.

(b) Procedure of Skin Traction:

Skin traction applies pulling force on skin to indirectly reduce and immobilize fractures:

Requirements:

(Note: Requirements are not needed to be listed in a theory exam; you just start the procedure.)

Scroll sideways to view the full table on small screens.

Top Shelf	Bottom Shelf	Bedside
Shaving tray	Receiver for used swabs	Hand washing equipment
Receiver containing:	Spreader	Screens
– A pair of dressing forceps, 21 dissecting forceps	Cordially, Brown wool or sorbo pads	Bucket for used equipment
– Bowl containing swabs	Tincture of benzoin co.	Weights in various kilograms
– Extension plaster	Dressing mackintosh and towel	On the bed: Pulleys, Fracture board
– A pair of scissors	A small blanket to cover the limb
– Crepe bandages	Balkan Beam
– Tape measure	Bed blocks
– Skin pencil

Procedure for Skin Traction

Scroll sideways to view the full table on small screens.

Steps	Action	Rationale
1.	Explain procedure to the patient.	Explanation encourages patient’s cooperation and relieves anxiety.
2.	Inspect the limb for sores. If skin has no lesions, put a mackintosh under the limb.	To prevent soiling the bed linen.
3.	Gently wash and dry the limb.	To prevent infections.
4.	Shave the part where the extension is to be applied.	To prevent loose hair entering into the wound.
5.	Apply tincture benzoin co. on the limb.	Benzoin co. reduces the irritating effect that strapping has on a sensitive skin.
6.	Measure the patient’s legs from the head of the tibia to above the malleoli line.	This will prevent the extension from sticking to the ankle.
7.	Cut an adequate extension strap, to fit on each side of the limb. Place a large wooden spreader in the middle of the limbs.	A wide spreader bar prevents the traction tape from rubbing on the patient’s bony prominences which can lead to sores.
8.	Position the limb gently and firmly while the doctor or orthopaedic officer applies the strapping.	To maintain bone alignment and promote healing.
9.	Apply crepe bandage over the strapping leaving the malleoli free. Put a soft padding over the ankles.	To prevent friction that can cause pressure sores.
10.	Make a knot at the end of the cord into the hole in the center of the spreader. Pass the cord over the pulley and attach to the weights.	The weights apply the pull for the traction. Properly hanging weights and correct patient positioning ensures accurate counterbalance and function of the traction.

SKIN TRACTION STEPS: “S-P-A-C-E-C-A-R-E” – Skin prep, Position, Adhesive strips, Countertraction weights, Elevation of bed, Assessment, Rope check, Evaluate

Points to Remember

Traction: Check that the strapping does not slip. Bandages should be secure and unwrinkled to avoid friction.

Inspection: Check the circulation of the foot and toes by noting color, temperature, sensation, and power. Neurovascular assessments aid in early identification of complications.

34 (a) Outline ten (10) points that nurses should consider while caring for a patient with tracheostomy. (10 marks)
(b) Outline the procedure nurses should follow while performing gastric lavage. (10 marks)

(a) Tracheostomy Care Considerations:

1. Airway patency: Ensure tube is patent, suction as needed using sterile technique. Observe for secretions, crusting, or tube obstruction. Have spare tube and obturator at bedside for emergencies.

2. Humidification and hydration: Provide adequate humidification via heat-moisture exchanger (HME) or trach collar to prevent mucus plugging and thick secretions.

3. Inner cannula cleaning: Clean inner cannula every 4-8 hours or when soiled using sterile normal saline. Inspect for patency and cracks. Replace disposable cannulas per policy.

4. Stoma and skin care: Clean stoma site with sterile saline or mild soap, inspect for infection, pressure necrosis, or skin breakdown. Dress with sterile gauze if draining.

5. Tube securing: Ensure ties/tape are secure but not too tight (1-2 finger space). Check for skin irritation from ties. Change ties daily or when soiled.

6. Infection control: Strict aseptic technique for suctioning and tube changes. Monitor for signs of infection (purulent secretions, fever, increased WBC). Perform hand hygiene before/after all care.

7. Communication: Provide alternative communication methods (pen/paper, communication boards) for patients with inflated cuffs. Deflate cuff and allow speech if patient can tolerate.

8. Cuff pressure management: Maintain cuff pressure 20-25 mmHg. Check every 8 hours. High pressure causes tracheal damage/necrosis; low pressure causes aspiration and poor ventilation.

9. Nutrition and swallowing: Assess gag reflex and swallowing ability. Elevate head of bed 30-45° during feeds to prevent aspiration. May need speech therapy evaluation.

10. Emergency preparedness: Keep spare tracheostomy tube, obturator, suction equipment, and bag-valve mask at bedside. Know emergency algorithm for accidental decannulation or tube blockage.

(b) Gastric Lavage Procedure:

Performed for poison ingestion or GI bleeding:

Requirements:

(Note: Requirements are not needed to be listed in a theory exam; you just start the procedure.)

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Trolley – Top Shelf	Trolley – Bottom Shelf	At the Bed Side
Rubber tubing, stomach tube, funnel	Mackintosh cape and towel	Suction machine if the patient is unconscious
Connection and clip	Receiver	Hand washing facilities
2 Gallipots	Jar for stomach contents	Screens
Bowl of swabs	Lubricant
Vomitus bowl	Adhesive strapping
20 ml syringe	Bucket for collecting stomach contents
Litmus paper	3 receivers
Jar of water

Procedure for Gastric Lavage

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Steps	Action	Rationale
1.	Follow the general rules. Collect the equipment needed and prepare the trolley. Explain the procedure to the patient. Screen the bed and close the adjacent windows. Bring the trolley to the bedside.	To enable cooperativeness. To ensure privacy. To prevent unnecessary movement.
2.	Place a bucket on the floor at the bedside.	To collect wastes.
3.	Request the patient to sit up if conscious. If unconscious, put the patient in a prone position and place a mackintosh cape and towel around the patient’s neck and bed clothes.	To protect the bed and patient.
4.	Connect up the funnel to the tubing using a connector but keep the stomach tube separate until it has been passed.	To prevent aspiration of the fluid by the patient.
5.	Lubricate the tube and pass it over the tongue into the pharynx and esophagus.	To ease passage of the tube.
6.	Keep on asking and encouraging the patient to swallow.	To gain patient’s cooperation.
7.	Connect the syringe on the tube and withdraw some stomach content.	To ensure that the tube is in the stomach.
8.	Test the stomach content with a litmus paper to confirm that you are in the stomach.	Acidic stomach content will turn blue litmus paper red.
9.	Clip the stomach tube with an artery forceps and place it in the receiver.	To prevent backflow of stomach contents.
10.	Apply a clip to the funnel and tubing then attach it to the stomach tube.	To prevent the flow of fluids before starting the procedure.
11.	Open the clip and allow approximately 300 mls of fluid to run into the lower funnel until level begins to rise. Invert the funnel into the bucket to siphon out the stomach contents. Repeat the procedure until the fluid which is returning is clear. Note the nature of the stomach contents.	To empty the stomach of unwanted or harmful contents.
12.	Clip the stomach tube, withdraw it from the stomach evenly and quickly, disconnect the tube from the funnel and tubing and place it in the receiver.	To prevent trauma to the patient.
13.	Give the patient a mouthwash, thank him and clear away the requirements.	To encourage patient’s comfort.
14.	Wash your hands and document the findings. (a). Type and amount of lavage solution used. (b). Appearance, odor, color, and amount of gastric return. (c). Patient’s tolerance to procedure. (d). Disposition of specimens. Clear away all the requirements.

GASTRIC LAVAGE STEPS: “A-I-R-W-A-Y-SAFE” – Assess, Insert, Remove, Wash, Activate charcoal, Yield sample, Secure airway, Avoid fluids, Finish, Evaluate

⚠️ DEBATED EFFICACY: Gastric lavage has limited benefit after 1 hour. Activated charcoal alone often sufficient. Protected airway is NON-NEGOTIABLE!

35 (a) Outline seven (7) actions that the nurse should perform during abdominal paracentesis. (7 marks)
(b) Outline the steps that should be followed while carrying out ear syringing. (13 marks)

(a) Nurse Actions During Abdominal Paracentesis:

1. Verify consent and check patient identity: Ensure informed consent obtained, explain procedure, verify patient with two identifiers per safety protocols.

2. Prepare and position patient: Place in semi-sitting position (45-90°) to facilitate fluid collection. Support with pillows for comfort and safety. Have patient void beforehand to empty bladder.

3. Prepare sterile field and equipment: Gather paracentesis kit, sterile drapes, local anesthetic (lidocaine 1%), collection bottles/bags, IV tubing, ultrasound if available. Maintain strict asepsis.

4. Monitor vital signs throughout: Record BP, HR, RR, SpO2 before, during (every 15 min), and after procedure. Watch for vasovagal response, hypotension, or respiratory distress from rapid fluid removal.

5. Assist with sterile draping and site preparation: Clean site with chlorhexidine or iodine, maintain sterile field. Site typically at midline 3cm below umbilicus or left/right lower quadrant.

6. Monitor for complications and support patient: Observe for pallor, diaphoresis, pain, anxiety. Provide reassurance. If large volume removed (>5L), give albumin/plasma expander per protocol to prevent circulatory collapse.

7. Label and send specimens: Label fluid specimens correctly (biochemistry, cytology, microbiology, cell count). Record total volume removed. Document procedure details and patient response.

8. Post-procedure care: Apply sterile dressing, return patient to comfortable position, recheck vitals, measure abdominal girth and weight. Monitor for leaks, bleeding, or peritonitis.

(b) Ear Syringing Procedure:

For cerumen (wax) removal when cerumenolytics fail:

Equipment:

(Note: Requirements are not needed to be listed in a theory exam; you just start the procedure.)

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Tray:	Bedside:
Ear Syringe in a Receiver Auroscope Basin and Vomitus Bowl Receiver Clean Gloves Mackintosh Cape Patient’s Towel Cotton Swabs Prescribed Solution: Boric acid 2-4% solution Sodium bicarbonate solution 1% Normal saline Hydrogen peroxide 2% Sterile water Bowl of warm water for solution temperature regulation	Adjustable Light and Screen Plastic Apron Handwashing Equipment

Procedure for ear irrigation

1. Explain the procedure to the patient to obtain consent and cooperation.

2. Provide privacy by screening or closing nearby windows.

3. Wash hands.

4. Prepare the equipment and bring at bedside.

5. Position the patient in sitting up.

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Steps	Action	Rationale
1.	Follow general rules of nursing procedures.
2.	Inspect the auditory canal using the otoscope under good light.
3.	Ask the patient to sit and tilt the head slightly toward the affected ear. Place the Mackintosh and towel over the shoulder and upper arm, under the affected ear. Place the curved part of the receiver below the tilted ear.
4.	Request the patient to support the receiver under the ear.
5.	Clean the auricle and meatus of the auditory canal with cotton wool swabs moistened with the solution.
6.	Fill the bulb syringe with irrigating solution. If an irrigating container is used, allow air to escape from tubing.	Air forced into the ear canal is noisy and therefore unpleasant for the patient.
7.	Straighten the auditory canal by pulling the auricle down and back for the child and up and back for an adult.	To straighten the auditory canal so that the solution can flow the entire length of the canal.
8.	Insert the tip of the syringe gently; direct a steady slow stream of solution against the roof of the auditory canal, using sufficient force to remove the secretions.	Gentleness aids in preventing injury to the tympanic membrane. Continuous in and out flow of the irrigating solution prevents pressure in the canal.
9.	Observe the patient throughout syringing.	To detect complications and be ready to act.
10.	When the irrigation is completed, place a cotton ball loosely in the auditory meatus and request the patient to lie on the affected ear on a towel or absorbent pad.	Cotton ball absorbs fluid while gravity allows remaining fluid in the canal to escape from the ear.
11.	Dry the patient’s auricle and remove the patient’s towel and Mackintosh cape.
12.	Wash hands.
13.	Document the procedure, appearance of discharge and patient’s response.
14.	Clean away.
15.	Decontaminate items used in the procedure.
16.	Return in 10 to 15 minutes and remove the cotton ball and review the patient.	To detect pain that may indicate injury to the tympanic.

EAR SYRINGING: “WARM-GENTLE-DRY” – Warm water, Assess, Reposition, Manipulate pinna, Irrigate, Not too forceful, Gentle, Lower head, Evaluate, Dry ear

👂 KEY POINTS: Contraindicated with perforated TM! Water must be body temp! Never direct jet at eardrum! Stop if pain/dizziness!

Original examination paper