ATI Custom NUR125 Exam 2 Summer
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A wound care nurse is caring for a client with a pressure injury.
Medical History
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Stage 2; Partial-thickness loss of skin
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Stage 3; Full-thickness loss of skin
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Stage 1; Superficial skin loss
Explanation
A Stage 2 pressure injury is characterized by partial-thickness loss of skin involving the epidermis and/or dermis. It presents as a shallow open wound with a red-pink wound bed, or as an intact or ruptured serum-filled blister. The nurse's notes describe exactly this — an exposed dermis and an intact serum-filled blister on the right hip — which are the defining clinical features of a Stage 2 pressure injury. The client's immobility, obesity, and decreased cardiac output are all contributing risk factors that further support this finding.
Why the other options are incorrect:
Stage 1 — A Stage 1 pressure injury presents as intact skin with non-blanchable redness over a localized area, typically over a bony prominence. There is no skin breakdown, blistering, or exposed dermis. The findings described in this case go beyond Stage 1.
Stage 3 — A Stage 3 pressure injury involves full-thickness skin loss where subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. The wound described here shows only an exposed dermis with a blister, which does not extend to the subcutaneous tissue layer required for Stage 3 classification.
Full-thickness loss of skin — Full-thickness skin loss is the hallmark of Stage 3 and Stage 4 pressure injuries, involving loss of the epidermis, dermis, and deeper tissue layers. The findings in this case involve only partial-thickness loss, not full-thickness loss.
Superficial skin loss — While a Stage 2 injury is relatively shallow, the correct and precise clinical term for the tissue loss seen in Stage 2 pressure injuries is partial-thickness loss of skin, not simply superficial skin loss. Partial-thickness specifically indicates that the epidermis and part of the dermis are involved, which aligns with the exposed dermis and intact blister described.
A nurse is planning routine hygiene care for a client experiencing frequent urinary incontinence. The nurse should plan to monitor the client for which of the following findings?
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Kidney stones
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Impaired skin integrity
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Skin shearing
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Hypoglycemia
Explanation
Frequent urinary incontinence exposes the skin to prolonged moisture, urine, and the chemical irritants found in urine. This leads to maceration and breakdown of the skin barrier, resulting in incontinence-associated dermatitis and ultimately impaired skin integrity. Monitoring for skin breakdown is the priority nursing concern during hygiene care for an incontinent client, and prompt cleansing and application of moisture barrier products are essential protective interventions.
Why the other options are incorrect:
A. Kidney stones — Kidney stones are associated with factors such as dehydration, dietary calcium or oxalate excess, and metabolic disorders. Urinary incontinence does not directly cause kidney stone formation and is not a monitoring priority related to hygiene care.
C. Skin shearing — Shearing occurs when layers of skin move in opposite directions due to friction and gravity, typically during repositioning. While immobile incontinent clients may be at risk for both shearing and skin breakdown, shearing is related to mechanical movement rather than urinary incontinence specifically.
D. Hypoglycemia — Hypoglycemia is a blood glucose disorder associated with diabetes management, insulin use, or inadequate nutritional intake. It has no direct relationship to urinary incontinence or hygiene care planning.
The nurse is caring for a client with impaired physical mobility. Which of the following is this client at risk of developing?
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Increased venous return in lower extremities leading to blood clots
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Decreased or absent bowel sounds leading to constipation
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Decreased lung expansion leading to retained secretions and pneumonia
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Increased urinary output leading to dehydration
Explanation
Immobility significantly impairs respiratory function. When a client cannot move freely, shallow breathing and reduced lung expansion lead to poor ventilation of the lung bases. This causes mucus and secretions to pool in the airways, creating an ideal environment for bacterial growth and increasing the risk of pneumonia and atelectasis. This is one of the most serious and well-documented complications of impaired physical mobility.
Why the other options are incorrect:
A. Increased venous return in lower extremities leading to blood clots — Immobility actually causes decreased venous return, not increased. Reduced muscle activity in the lower extremities impairs the venous pump mechanism, causing blood to stagnate in the veins and increasing the risk of deep vein thrombosis.
B. Decreased or absent bowel sounds leading to constipation — While constipation is a valid complication of immobility due to decreased peristalsis, the statement is partially incorrect. It is reduced peristalsis, not absent bowel sounds, that leads to constipation in immobile clients. Absent bowel sounds would indicate a more serious condition such as ileus.
D. Increased urinary output leading to dehydration — Immobility does not cause increased urinary output. Rather, it leads to urinary stasis, incomplete bladder emptying, and increased risk of urinary tract infections and kidney stones due to calcium being released from inactive bones increasing urinary calcium concentration.
The nurse has received shift report on a post-surgical unit. Which client should the nurse see first related to immobility concerns and bone loss?
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A 55-year-old with a history of osteoporosis who reports new back pain
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A 44-year-old recovering from a left arm sports injury who reports occasional stiffness on post-op day 3
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A 70-year-old with a history of metastatic bowel cancer who reports occasional stiffness while ambulating in the morning
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An 18-year-old with a history of diabetes mellitus type 1 who reports loss of muscle tone following cast removal
Explanation
A client with a known history of osteoporosis — a condition characterized by decreased bone density — who is reporting new back pain in the post-surgical setting requires immediate assessment. New back pain in this population raises urgent concern for a pathological vertebral compression fracture, which can occur with minimal or no trauma. This is the highest priority client because the combination of bone loss history and a new, potentially serious symptom demands prompt evaluation before the condition worsens.
Why the other options are incorrect:
B. A 44-year-old recovering from a left arm sports injury who reports occasional stiffness on post-op day 3 — Occasional stiffness on post-op day 3 following a sports injury is an expected finding in early recovery and does not indicate an urgent immobility or bone loss concern.
C. A 70-year-old with a history of metastatic bowel cancer who reports occasional stiffness while ambulating in the morning — While this client has complex needs, morning stiffness during ambulation is a less urgent finding compared to new back pain in an osteoporotic client. Morning stiffness is common and does not represent an acute change requiring immediate intervention.
D. An 18-year-old with a history of diabetes mellitus type 1 who reports loss of muscle tone following cast removal — Muscle atrophy and loss of tone following cast removal is an expected and anticipated complication of prolonged immobilization. This client requires rehabilitation planning but does not present an urgent or emergent concern compared to the osteoporotic client with new pain.
A nurse is using the Braden Scale to assist in the assessment of a newly admitted client. Which of the following does the Braden Scale assess?
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Stage of pressure injury
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Risk for pressure injury
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Risk for falls
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Level of consciousness
Explanation
46-year-old female client was admitted for emergent removal of an infected appendix 1 day ago. Surgical removal of the appendix was performed successfully. Client was transferred to the medical-surgical unit for postoperative care.
Nurses' Notes
The client is requesting assistance with hygiene this morning. She states "I have not bathed for 4 days." The client does not make eye contact and looks down at her hands when requesting help with hygiene.
Choose the 3 responses by the male nurse that reflect consideration of the client's potential cultural variables related to hygiene care.
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"What are your preferences for the use of soap and deodorant?"
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"I am not comfortable helping a female client with hygiene care, I will find someone who can help."
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"Why have you not bathed for 4 days?"
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"Would you prefer a care provider of your same gender to help you?"
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"Would you like for a family member to help you with hygiene?"
Explanation
Cultural competence in hygiene care requires the nurse to assess personal preferences, respect modesty and gender-related values, and offer alternatives that honor the client's cultural background. Asking about product preferences respects personal and cultural hygiene practices. Offering a same-gender provider acknowledges that many cultures, particularly those with strong modesty norms, prefer same-gender care for intimate hygiene. Offering family involvement recognizes that in many cultures, family members play an active role in personal care and the client may feel more comfortable with a trusted family member assisting.
Why the other options are incorrect:
B. "I am not comfortable helping a female client with hygiene care, I will find someone who can help." — While the intention of finding a same-gender provider may be appropriate, framing it as the nurse's personal discomfort is unprofessional and shifts the focus away from the client's needs. The offer should be centered on the client's preferences, not the nurse's feelings.
C. "Why have you not bathed for 4 days?" — This question is judgmental in tone and does not reflect cultural sensitivity. The client has been hospitalized and just had emergency surgery, and the phrasing implies criticism rather than expressing concern or offering assistance in a respectful manner.
A nurse is repositioning a client into a lateral position to prevent pressure injuries. Which bony prominences should the nurse prioritize assessing for skin breakdown?
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Greater trochanter, shoulder, and ankles
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Chin, elbow, and anterior thighs
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Occiput, scapulae, and elbows
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Ileum, clavicle, and humerus
Explanation
Massaging the lower extremities of a client suspected of having a DVT is contraindicated and dangerous. If a thrombus is present, massaging the leg can dislodge the clot and cause it to travel to the lungs, resulting in a pulmonary embolism — a life-threatening emergency. The nurse must intervene immediately to stop this action.
Why the other options are incorrect:
A. Evaluate if the client has any risk factors for DVT — Risk factor assessment is an appropriate and important step in DVT screening. Immobility, recent surgery, obesity, and history of clotting disorders are all relevant risk factors to evaluate.
B. Inspect the client's lower extremities for redness, swelling, or cyanosis — Visual inspection is a safe and appropriate assessment technique. Unilateral redness, warmth, swelling, and discoloration are classic clinical signs of DVT that the nurse should assess for.
D. Measure the circumference of the client's calves for symmetry — Calf circumference measurement is a safe, non-invasive technique used to detect unilateral swelling that may indicate DVT. A difference of 2 cm or more between calves is clinically significant and warrants further investigation.
The nurse is providing education about the importance of proper foot care to a client diagnosed with diabetes mellitus type 2. Which primary goal is the nurse trying to achieve?
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Prevention of amputation
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Prevention of joint stiffness
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Prevention of poor hygiene
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Prevention of hypoglycemia
Explanation
In clients with type 2 diabetes mellitus, peripheral neuropathy and peripheral vascular disease reduce sensation and impair circulation in the lower extremities. Minor foot injuries such as cuts, blisters, or pressure sores can go unnoticed and progress to serious infections, gangrene, and ultimately limb amputation if not identified and treated early. Proper foot care education — including daily inspection, appropriate footwear, and nail care — is primarily aimed at preventing this devastating complication.
Why the other options are incorrect:
B. Prevention of joint stiffness — Joint stiffness is not a primary complication targeted by diabetic foot care education. While musculoskeletal complications can occur in diabetes, they are not the focus of foot care teaching.
C. Prevention of poor hygiene — Hygiene is a component of foot care, but it is a means to an end rather than the primary goal. The ultimate objective of maintaining foot hygiene in a diabetic client is to prevent wound development and subsequent amputation.
D. Prevention of hypoglycemia — Hypoglycemia is managed through blood glucose monitoring, medication management, and dietary adjustments. It is not related to foot care education and is not a complication that proper foot care addresses.
A nurse is preparing to provide hygiene care to a client with a peripheral oxygen saturation (SpO₂) of 88%. How will the nurse position the client when providing hygiene care?
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High-Fowler's position
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Supine with legs elevated
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Trendelenburg
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Side-lying (lateral) position
Explanation
An SpO₂ of 88% is below the normal range of 95 to 100% and indicates hypoxemia. Positioning the client in High-Fowler's position — with the head of the bed elevated between 60 to 90 degrees — maximizes lung expansion, reduces the work of breathing, and improves oxygenation by allowing the diaphragm to descend fully and the lungs to expand more effectively. This position is the priority for any client experiencing respiratory compromise.
Why the other options are incorrect:
B. Supine with legs elevated — Elevating the legs in a supine position increases venous return to the heart and lungs, which can worsen respiratory distress in a client who is already hypoxic. This position is used for shock management, not for improving oxygenation in a client with low SpO₂.
C. Trendelenburg — The Trendelenburg position places the client flat with the feet higher than the head, which shifts abdominal organs upward and restricts diaphragmatic movement, significantly worsening breathing and oxygenation. This position is contraindicated in clients with respiratory compromise.
D. Side-lying (lateral) position — While the lateral position may be appropriate for certain care tasks and can be protective for skin integrity, it does not optimize lung expansion or oxygenation as effectively as High-Fowler's position for a client with an SpO₂ of 88%.
A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
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Increased metabolic rate
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Decreased motivation
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Impaired circulation
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Urinary stasis
Explanation
Pressure injuries develop when sustained mechanical pressure compresses blood vessels, reducing or cutting off blood flow to the skin and underlying tissues. In clients with impaired mobility, the inability to reposition frequently leads to prolonged pressure on bony prominences. Impaired circulation — whether from the pressure itself or from underlying vascular conditions — is the direct physiological mechanism by which tissue ischemia and subsequent pressure injury occur.
Why the other options are incorrect:
A. Increased metabolic rate — Immobility typically leads to a decreased metabolic rate over time, not an increased one. While altered metabolism affects overall healing capacity, it is not the primary factor linking impaired mobility to pressure injury development.
B. Decreased motivation — While decreased motivation may contribute to reluctance to reposition or participate in care, it is a psychosocial factor rather than the direct physiological cause of pressure injury in an immobile client.
D. Urinary stasis — Urinary stasis is a serious complication of immobility related to incomplete bladder emptying and increased UTI risk. While urinary incontinence can contribute to skin breakdown, urinary stasis itself is not the primary factor responsible for pressure injury development.
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