ATI NUR 109 Final Assessment Exam

The correct answer is B: Stage II

Explanation:

A Stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough, or as an intact or ruptured serum-filled blister. This matches the scenario described.

Why the other options are incorrect:

A. Stage I

This stage involves intact skin with non-blanchable redness. There is no open wound or loss of dermis.

C. Stage III

Stage III involves full-thickness tissue loss, possibly exposing subcutaneous fat, but not bone, tendon, or muscle. There may also be slough, which is not present here.

D. Stage IV

This is full-thickness tissue loss with exposed bone, tendon, or muscle. The described wound does not reach that depth.

E. Unstageable

A wound is unstageable when the base is covered with slough or eschar, preventing depth assessment. In this case, the wound bed is clearly visible and not obscured.

Summary:

Option B is correct because the wound described has partial-thickness loss of dermis, a red-pink bed, and no slough, which are hallmark signs of a Stage II pressure ulcer.

The correct answer is A: Autonomy

Explanation:

Autonomy is the ethical principle that refers to an individual's right to make their own decisions regarding their body and treatment, as long as they have the capacity to do so. In this case, the client with an eating disorder is refusing to drink a prescribed supplement. If the nurse respects that decision, they are upholding the client’s autonomy—even if the refusal goes against medical advice.

This principle is central to patient-centered care and informed consent. Even when the healthcare team believes a treatment is beneficial, they must respect the patient’s right to refuse it if the patient is mentally competent and informed of the consequences.

Why the Other Options Are Incorrect:

B. Fidelity

Fidelity refers to being faithful to commitments made to the client and maintaining trust. While important in all care relationships, this situation is more specifically about respecting the client’s decision-making rights.

C. Veracity

Veracity involves truth-telling and honesty. It is essential in client education and communication but is not directly related to allowing the client to refuse a supplement.

D. Beneficence

Beneficence is the ethical duty to promote good and act in the client’s best interest. Encouraging the client to take the supplement would align with beneficence, but allowing them to refuse it demonstrates autonomy.

Summary:

By allowing the client to refuse the supplement, the nurse is honoring the ethical concept of autonomy (Option A), which supports the client’s right to make informed decisions about their own care.

The correct answer is C: Developing and implementing a culturally competent health education program tailored to underserved populations to improve access to preventive services.

Explanation:

Healthy People 2030 is a national initiative that aims to eliminate health disparities, achieve health equity, and improve the health of all population groups. One of its core objectives is addressing social determinants of health and expanding access to preventive services, especially in underserved communities.

Option C demonstrates a direct application of these goals by promoting culturally competent care, which respects clients' diverse backgrounds and enhances the effectiveness and accessibility of health education. Tailoring programs to the unique needs of underserved populations helps remove barriers such as language, cultural misunderstandings, and limited access to care—core strategies in reducing disparities.

Why the Other Options Are Incorrect:

A. Prioritizing high-cost interventions...

This approach neglects preventive care and early intervention, which are emphasized in Healthy People 2030 as crucial to improving outcomes and reducing disparities. Focusing only on advanced diseases reinforces existing inequities.

B. Focusing only on individual client care...

This ignores the broader context of health, such as income, education, housing, and environment. Healthy People 2030 stresses the importance of addressing social determinants of health to improve population outcomes.

D. Providing standard health education materials...

Uniform education without cultural or linguistic adaptation can exclude or confuse clients from diverse backgrounds. This contradicts the Healthy People 2030 emphasis on equitable access and culturally responsive care.

Summary:

Option C best aligns with Healthy People 2030’s objectives by reducing health disparities through targeted, culturally sensitive interventions that improve access to preventive services among underserved populations.

The correct answer is C: Spirituality can increase emotional and psychological comfort.

Explanation:

Spirituality is a core component of holistic care, especially for clients nearing the end of life. It encompasses a person's beliefs, values, meaning, and purpose in life. Research and clinical practice have shown that spirituality can help individuals cope with suffering, enhance quality of life, and provide emotional and psychological comfort during terminal illness or in palliative care settings. Supporting a client’s spiritual needs can alleviate anxiety, fear, and existential distress, thereby improving overall well-being as they approach the end of life.

Why the Other Options Are Incorrect:

A. Spirituality can increase depression.

This is incorrect. In most cases, spirituality serves as a source of support and resilience, reducing feelings of depression and helping clients find peace.

B. Spirituality can increase feelings of hopelessness.

Incorrect. Spiritual engagement typically promotes hope, even in the face of terminal illness. It can help clients find meaning and purpose, which fosters hope and acceptance.

D. Spirituality can increase the desire to hasten death.

This is also incorrect. Spiritual care often reduces the desire for hastened death, as it addresses emotional, existential, and spiritual suffering that might otherwise lead to such thoughts.

Summary:

The nurse should teach that spirituality can increase emotional and psychological comfort (Option C) for clients near the end of life, promoting peace, meaning, and coping during a vulnerable time.

The correct answer is A: Subclavian and jugular veins

Explanation:

Total parenteral nutrition (TPN) requires administration through a central venous catheter because the solution is hypertonic and can cause irritation or damage to smaller peripheral veins. The subclavian vein and the internal jugular vein are the most commonly used access points for central venous catheter placement. These veins provide a direct route to the superior vena cava, allowing rapid dilution of the hypertonic solution and reducing the risk of phlebitis or infiltration.

Why the other options are incorrect:

B. Brachial and subclavian veins:

The brachial vein is a peripheral vein and is not suitable for long-term TPN administration.

C. Femoral and jugular veins:

The femoral vein can be used in emergencies but is not preferred due to higher infection risk and limited mobility.

D. Brachial and femoral veins:

Both are peripheral or less ideal for long-term central access, with higher risks of infection or thrombosis.

Summary:

Correct answer: A. The subclavian and jugular veins are preferred for central line placement used in TPN because they allow safe, long-term administration of hypertonic solutions directly into the central circulation.

The correct answer is A: Most old people have dependent functioning

Explanation:

Option A is NOT true. While some older adults may experience limitations in physical or cognitive function due to age-related changes or illness, the majority of older adults remain functionally independent, especially with appropriate support, healthcare, and resources. Promoting a stereotype of dependency is not only inaccurate but also disempowering and can negatively impact care planning and patient dignity.

Why the other options are true:

B. Most old people have strengths we should focus on

This is true. Older adults possess valuable life experience, resilience, and coping skills. Focusing on strengths supports positive aging and holistic care.

C. Most old people should be involved in care decisions

This is true. Involving older adults in their own care decisions supports autonomy, respects person-centered care principles, and often leads to better outcomes.

D. Most old people should be encouraged to have independence

This is true. Promoting independence helps maintain self-esteem, function, and quality of life. It is a key goal in geriatric care.

Summary:

Option A is the false statement. Most older adults are not dependent, and assuming so undermines their capabilities and autonomy.

The correct answer is C: Take the medication with food.

Explanation:

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used to manage pain and inflammation. One of the most important nursing considerations is gastrointestinal (GI) safety, as ibuprofen can irritate the stomach lining and increase the risk for gastritis, ulcers, and bleeding. Taking the medication with food, milk, or a full glass of water helps minimize GI upset and protect the stomach lining.

Why the Other Options Are Incorrect:

A. Sustained-release forms may be crushed for easier administration.

This is incorrect. Sustained-release (SR) or extended-release (ER) medications should never be crushed, as it destroys the time-release mechanism, leading to rapid absorption and potential toxicity or side effects.

B. Taking the maximum dose will offer stroke prevention.

This is incorrect and dangerous. Ibuprofen does not prevent strokes—in fact, long-term or high-dose use of NSAIDs like ibuprofen may increase the risk of cardiovascular events, including stroke and heart attack.

D. Take the medication with an aspirin to increase effectiveness.

This is incorrect. Taking aspirin with ibuprofen increases the risk of GI bleeding and can interfere with aspirin’s cardioprotective effects. They should only be used together under close medical supervision.

Summary:

The safest and most appropriate instruction is C, take the medication with food, to reduce gastrointestinal side effects commonly associated with ibuprofen use.

The correct answer is A: Ensure that all electrical cords and wires are secured against walls and out of walkways.

Explanation:

Clients with glaucoma experience peripheral vision loss, which increases the risk of tripping over unseen obstacles, especially those located outside of central vision fields. Unsecured electrical cords and wires in walkways present a major fall hazard for visually impaired individuals. Prioritizing the removal or securing of these tripping hazards is essential for ensuring immediate physical safety in the home environment.

While other options also support a safer environment or improved navigation, eliminating immediate hazards that could cause injury is the most critical first step in fall prevention and home safety for clients with low vision.

Why the Other Options Are Incorrect:

B. Install bright, overhead lighting...

Improved lighting is helpful but does not address the specific hazard of physical obstructions, which poses a more immediate risk for falls in glaucoma patients.

C. Place throw rugs and carpets...

This is incorrect and dangerous. Throw rugs increase the risk of tripping and slipping, especially for those with vision loss, and should be removed, not added.

D. Encourage the client to use a walking stick or guide dog...

While assistive devices are beneficial for orientation and independence, this option may not be immediately practical or accessible and doesn’t address environmental hazards.

E. Label kitchen cabinets and drawers...

Labeling helps with independence in daily activities but is secondary to ensuring a hazard-free, physically safe environment.

Summary:

The most immediate and safety-focused intervention is A, securing electrical cords and wires to prevent falls—this directly addresses the major risk posed by visual impairments like glaucoma.

The correct answer is D: Naloxone

Explanation:

Naloxone is an opioid antagonist that reverses the effects of opioids such as morphine. It works by binding to opioid receptors and blocking or reversing the effects of opioid drugs, including respiratory depression, sedation, and hypotension. Because morphine is a potent opioid, there is a risk of overdose or respiratory compromise, especially with IV administration. Therefore, naloxone must be readily available whenever morphine is given to ensure prompt intervention if adverse effects occur.

Why the Other Options Are Incorrect:

A. Flumazenil

Flumazenil is an antidote for benzodiazepine overdose (e.g., diazepam, lorazepam). It is not effective against opioids like morphine and would not reverse opioid-induced respiratory depression.

B. Protamine

Protamine sulfate is used to reverse the anticoagulant effects of heparin. It has no effect on opioids and is unrelated to morphine toxicity management.

C. Neostigmine

Neostigmine is used to treat myasthenia gravis and to reverse neuromuscular blockade caused by certain anesthetic agents. It does not counteract opioids and would not be useful in a morphine-related emergency.

Summary:

The nurse should have naloxone (Option D) available when administering IV morphine to manage potential opioid overdose or respiratory depression. Naloxone is the only appropriate reversal agent among the options listed.