NUR 125 Final Exam Fall

Correct Answers

Stage 3 pressure injury

Open burn area

Detailed Explanation of the Correct Answers

Stage 3 pressure injury

A stage 3 pressure injury involves full-thickness skin loss that may extend into the subcutaneous tissue. These types of wounds usually heal by secondary intention because the wound edges cannot be approximated. Healing occurs gradually through the formation of granulation tissue, contraction of the wound edges, and epithelialization.

Open burn area

An open burn area typically involves tissue destruction where the skin is not intact, and wound edges cannot be brought together. These wounds also heal by secondary intention through granulation, wound contraction, and epithelialization over time.

Explanation of Incorrect Options

Sutured surgical incision

This is an example of healing by primary intention, where the wound edges are brought together (approximated) and closed with sutures, staples, or adhesive. Healing is quicker with minimal scarring.

Casted bone fracture

A casted bone fracture involves internal tissue healing (bone) and is not related to skin wound healing by primary, secondary, or tertiary intention. This is outside the scope of the wound healing classification.

Laceration sealed with adhesive

Similar to a sutured incision, a laceration closed with skin adhesive heals by primary intention because the wound edges are approximated, promoting faster healing with minimal granulation.

Summary

Wounds that heal by secondary intention are typically large, open, or involve tissue loss, such as a stage 3 pressure injury or open burn area. In contrast, wounds that are closed surgically or sealed heal by primary intention, and bone fractures do not fall under the skin wound healing categories.

Correct Answers:

Make sure that the client’s call light is within reach

Provide the client with nonskid footwear

Complete a fall-risk assessment

Detailed Explanation of the Correct Answers:

Make sure that the client’s call light is within reach

Ensuring that the call light is within the client’s reach promotes independence and safety by allowing them to call for help rather than attempting to get up unassisted, which could lead to another fall. This is a fundamental fall prevention strategy in all healthcare settings.

Provide the client with nonskid footwear

 Nonskid footwear provides better traction and stability when the client is walking, reducing the risk of slipping and falling. Clients, especially those in long-term care facilities, are at increased risk of falling due to weakened mobility, and proper footwear is essential in preventing falls.

Complete a fall-risk assessment

A fall-risk assessment helps identify a client’s specific risk factors (such as medications, mobility limitations, or cognitive changes) so that appropriate fall prevention measures can be tailored to the individual’s needs. This should be done after any fall and routinely thereafter.

Explanation of Incorrect Options:

Place a belt restraint on the client when they are sitting on the bedside commode

The use of physical restraints like a belt restraint is generally discouraged and should only be used as a last resort. Restraints can actually increase the risk of injury and psychological distress, and they do not guarantee fall prevention. Additionally, this client is alert, oriented, and able to follow directions, which makes restraints unnecessary and inappropriate.

Keep the bed in its lowest position with all side rails up

While keeping the bed in the lowest position is appropriate for safety, raising all side rails can be dangerous. Four raised side rails are considered a form of restraint and can cause injury if the client attempts to climb over them. Instead, only the necessary number of side rails should be raised based on the client's condition and needs.

Summary:

The nurse should take non-restrictive, client-centered actions to prevent future falls. Ensuring the call light is within reach, providing nonskid footwear, and completing a fall-risk assessment are all effective and appropriate measures. Using restraints or raising all four side rails can pose greater risks and are not recommended for a client who is alert and able to follow directions.

 Correct Answer: Have the client breathe into a paper bag

Explanation 

Breathing into a paper bag is an appropriate intervention for respiratory alkalosis caused by hyperventilation. When a person hyperventilates, they exhale excessive amounts of carbon dioxide (CO₂), leading to a rise in blood pH (alkalosis). Breathing into a paper bag helps the client rebreathe exhaled CO₂, increasing the CO₂ levels in the blood and helping restore acid-base balance. This is a short-term, non-invasive technique often used in anxiety-induced hyperventilation.

Why The Other Options Are Incorrect

Plan to administer sodium bicarbonate to the client:

Sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. Administering sodium bicarbonate in this case could worsen the alkalosis by further increasing the pH of the blood.

 Plan to administer insulin to the client:

Insulin is appropriate in cases of diabetic ketoacidosis (a metabolic acidosis), not respiratory alkalosis. There is no indication that this client has hyperglycemia or ketone production, so insulin is not relevant here.

Have the client place their head between their knees:

Placing the head between the knees may help temporarily improve cerebral blood flow in someone feeling faint, but it does not address the cause or correction of respiratory alkalosis. It has no effect on ventilation or CO₂ levels, and therefore, it is not an effective treatment in this context.

Summary

The appropriate action for a client experiencing respiratory alkalosis due to hyperventilation is to have them breathe into a paper bag, which helps retain CO₂ and restore acid-base balance. Sodium bicarbonate and insulin are treatments for metabolic acidosis, not respiratory alkalosis, and placing the head between the knees does not affect CO₂ levels.

 Correct Answer: Perform a bladder scan.

Explanation

Performing a bladder scan is the first action the nurse should take when a client has not voided for 8 hours after catheter removal. A bladder scan is a noninvasive, painless, and quick diagnostic tool used to determine the volume of urine in the bladder. This helps the nurse assess whether the client is experiencing urinary retention, or if the bladder is empty and no intervention is necessary. It guides appropriate next steps, such as catheterization or conservative measures.

Why The Other Options Are Incorrect

Increase fluids:

While increasing fluid intake may encourage urination, it is not the first priority. The nurse needs to assess whether the bladder is already full before encouraging more intake, which could worsen urinary retention and lead to bladder distension or damage.

Insert a straight catheter:

Straight catheterization should be performed only if the bladder scan confirms retention and the client is unable to void. Inserting a catheter without assessing bladder volume first may result in unnecessary and invasive intervention.

Provide assistance to bathroom:

While assisting the client to the bathroom might be helpful if the client simply needs help to void, the priority is to assess whether there is urine in the bladder at all. If the bladder is not full, this step would be ineffective.

Summary

When a client has not voided after 8 hours post-catheter removal, the first priority is to assess bladder volume using a bladder scan. This determines the presence and amount of urine, helping guide further action. Increasing fluids, catheterization, or bathroom assistance are considered secondary measures based on the scan’s results.

The correct transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC) are:

Droplet precautions

Airborne precautions

Contact precautions

Detailed Explanations:

Droplet precautions: These precautions are used for diseases that are spread through respiratory droplets that are produced when an infected person coughs, sneezes, or talks. Examples of conditions that require droplet precautions include influenza, pertussis, and COVID-19. Healthcare workers should wear a mask when within 3 feet of the patient, and the patient should wear a mask during transport.

Airborne precautions: These precautions are used for diseases that are spread through tiny airborne particles that can remain suspended in the air for long periods. Diseases like tuberculosis, measles, and chickenpox require airborne precautions. Healthcare workers must wear an N95 respirator, and the patient should be placed in a negative pressure room.

Contact precautions: These precautions are used for infections that can be transmitted by direct or indirect contact with an infected patient or their environment. Conditions requiring contact precautions include Clostridioides difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA), and norovirus. Healthcare workers should wear gloves and gowns when interacting with the patient or touching surfaces that may be contaminated.

Why the other options are incorrect:

Microbial precautions: This is not an official category of transmission-based precautions defined by the CDC. The CDC uses specific terms like droplet, airborne, and contact precautions.

Respiratory precautions: While respiratory protection is essential in some scenarios (such as for airborne diseases), the CDC does not have a specific category of "respiratory precautions" as part of its transmission-based precautions. Instead, airborne or droplet precautions would apply depending on the nature of the infection.

Body fluid precautions: While body fluids may be involved in the transmission of some infections, the CDC does not use "body fluid precautions" as an official category. Standard precautions cover the need for appropriate handling of body fluids (e.g., using gloves, gowns, and masks as needed).

Summary:

The CDC defines three main types of transmission-based precautions: droplet precautions, airborne precautions, and contact precautions. "Microbial," "respiratory," and "body fluid" precautions are not recognized categories by the CDC.

 Correct Answer: Serosanguineous

Detailed Explanation of the Correct Answer:

Serosanguineous

This is the correct answer because serosanguineous drainage is a mixture of clear (serous) fluid and blood. It appears watery with a pink or light red tint, indicating the presence of both serum and small amounts of blood. This type of drainage is commonly seen in healing wounds and is generally expected in the early stages of wound healing.

Explanation of Incorrect Options:

 Sanguineous

 Sanguineous drainage is primarily composed of blood. It is bright red and thicker, indicating active bleeding, possibly from capillaries or deeper vessels. It would not appear watery.

Serous

 Serous drainage is clear or slightly yellow and watery with no blood. It’s typically seen in wounds healing without infection and represents plasma.

 Purulent

Purulent drainage is thick, cloudy, and often green, yellow, or brown, indicating infection. It contains pus, which is a mix of dead white blood cells, bacteria, and tissue debris.

Summary:

The correct documentation for watery red drainage is serosanguineous, which is a normal finding in early wound healing. It differs from sanguineous (bloody), serous (clear), and purulent (pus-filled, often infected) drainage types.

 Correct Answer: Agitation

Explanation

Agitation is a common early sign of hypoxemia, particularly during an asthma attack. When oxygen levels begin to drop, the brain is affected first, leading to neurological changes such as restlessness, anxiety, irritability, or agitation. These symptoms occur before other, more severe signs manifest. In an asthma attack, airways become inflamed and narrowed, reducing airflow and oxygen delivery to tissues, which triggers these behavioral and cognitive changes.

Why The Other Options Are Incorrect

 Dysphagia:

Dysphagia refers to difficulty swallowing and is not a typical manifestation of hypoxemia. It is usually associated with neurological or structural disorders affecting the esophagus or throat, not with oxygen deprivation during an asthma attack.

Nausea:

Although nausea can occur in various conditions, it is not a primary or early sign of hypoxemia. It may occur as a nonspecific symptom in severe hypoxia or other medical issues, but it is not commonly associated with asthma-induced hypoxemia.

 Hypotension:

Hypotension may be a late and serious sign of prolonged or severe hypoxemia, indicating possible respiratory failure or shock, but it is not an early indicator. Early signs are more neurologically oriented, such as restlessness and agitation.

Summary

The most reliable early indicator of hypoxemia during an asthma attack is agitation (A) due to decreased oxygen delivery to the brain. Dysphagia, nausea, and hypotension are not typical early signs and are less directly related to oxygen deprivation in this context.

 Correct Answer: Give with orange juice.

Detailed Explanation of the Correct Answer

Ferrous sulfate is best absorbed in an acidic environment, and vitamin C (ascorbic acid) enhances the absorption of iron. Orange juice is high in vitamin C, making it an excellent choice to take with ferrous sulfate. This practice improves iron uptake in the gastrointestinal tract and can help increase hemoglobin levels more effectively in children with iron deficiency anemia.

Why The Other Options Are Incorrect

Administer at mealtimes:

Iron supplements are best absorbed on an empty stomach. Administering ferrous sulfate with meals may reduce gastrointestinal discomfort but also significantly reduces iron absorption due to interaction with food components like calcium and fiber.

Administer at bedtime:

Taking iron supplements at bedtime is not typically recommended because lying down may increase the risk of gastrointestinal side effects such as nausea or reflux. Additionally, the timing doesn’t optimize iron absorption unless it’s several hours after eating.

 Give with a 240 mL (8 oz) glass of milk:

Milk should be avoided when giving iron supplements because it contains calcium and casein, both of which inhibit iron absorption. Milk binds with iron in the GI tract and prevents it from being effectively absorbed.

Summary

To maximize the effectiveness of ferrous sulfate in treating iron deficiency anemia, the nurse should instruct the parents to give it with orange juice (C) to enhance absorption. Meals, bedtime dosing, and milk can all interfere with absorption or increase side effects, making them less appropriate choices.

Correct Answer: Walk to a safe area.

Explanation

The nurse’s first priority in the event of a fire is to ensure personal and client safety by removing individuals from immediate danger. This aligns with the RACE acronym used in fire safety protocol:

R – Rescue anyone in immediate danger

A – Alarm (activate the fire alarm)

C – Contain the fire by closing doors

E – Extinguish or evacuate

By walking to a safe area, the nurse initiates the “Rescue” step, removing themselves (and potentially clients) from harm’s way. This must be done before any other actions to ensure survival and safety.

Why The Other Options Are Incorrect

Close all the doors:

This is part of the “Contain” step in the RACE acronym and helps prevent the spread of smoke and flames. However, it should be done after rescuing people from danger. Closing doors while people are still in danger zones delays evacuation and increases risk.

Stay close to the ground:

While this helps avoid inhaling smoke (since smoke rises), it is not the first priority unless the nurse is trapped and trying to escape. The initial action should be to move to a safe area, not simply drop to the floor.

 Wrap clients in blankets:

Wrapping clients in blankets may be helpful after evacuation, especially if they are exposed to cold or smoke, but it is not a first-line action. It delays immediate removal from danger, which is more critical in a fire situation.

Summary

The first action in response to a fire or smoke is to walk to a safe area, in line with the “Rescue” step of fire response. Closing doors, staying low, and using blankets are secondary interventions that support safety but do not take precedence over immediate evacuation from danger.