NUR 125 Final Exam Fall

Correct Answers:

The inner wrapping of an item on the sterile field

An irrigation syringe appropriately placed on the sterile field

One gloved hand with the other gloved hand

Detailed Explanation of Correct Answers:

The inner wrapping of an item on the sterile field

This is correct. The inner wrapping of a sterile item is considered part of the sterile field, and touching it with sterile gloves does not break sterile technique.

An irrigation syringe appropriately placed on the sterile field

Correct. If the syringe was placed using sterile technique, it is part of the sterile field and can be handled with sterile gloves.

 One gloved hand with the other gloved hand

Correct. Both gloves are sterile, so touching one sterile gloved hand with the other maintains sterility.

Why the Incorrect Options Are Wrong:

A bottle containing a sterile solution

Incorrect. The outside of the bottle is not sterile, even if the solution inside is. Touching the outside of the bottle with sterile gloves contaminates the gloves.

The edge of the sterile drape at the base of the field

Incorrect. The outer 1-inch border of a sterile drape is considered contaminated, and sterile gloves should not come into contact with it.

Summary:

The nurse may safely touch with sterile gloves:

The inner sterile wrapping

Sterile items properly placed on the field 

Their other sterile-gloved hand

They must avoid touching:

Non-sterile surfaces like solution bottles 

The contaminated border of the sterile field

Correct Answer: Use night-lights in bedrooms and bathrooms.

Detailed Explanation:

Use night-lights in bedrooms and bathrooms:

This is the most appropriate and effective intervention to help prevent falls in an older adult with visual impairment and decreased mobility. Night-lights improve visibility during nighttime hours, reducing the risk of tripping or losing balance when moving around, especially when going to the bathroom.

Why the other options are incorrect:

Install 60-watt light bulbs in stairways:

While lighting is important, 60-watt bulbs may not provide sufficient brightness for someone with a visual impairment. Brighter lighting (e.g., 75–100 watts or LED equivalents) is usually more appropriate for stairways to reduce fall risk.

Place throw rugs in high traffic areas:

This is unsafe. Throw rugs are a well-known tripping hazard, especially for individuals with impaired mobility or vision. They should be removed or secured with non-slip backing if necessary.

Use ladders and step stools to reach high items:

This is dangerous for someone with decreased mobility. The client should avoid climbing, and frequently used items should be stored within easy reach to prevent accidents.

Summary:

To reduce fall risk in older adults with visual and mobility impairments, enhancing visibility at night is crucial. The safest and most effective advice is to use night-lights in key areas like bedrooms and bathrooms.

Correct Answer: A (retinol)

Explanation 

Vitamin A (retinol) is essential for maintaining normal vision, particularly night vision. It is a fat-soluble vitamin involved in the formation of rhodopsin, a pigment in the retina that allows the eyes to adjust in low-light conditions.

A deficiency in vitamin A can lead to night blindness (nyctalopia), which is often the earliest symptom of deficiency. In severe cases, it may progress to xerophthalmia and corneal damage, especially in malnourished individuals or those with fat absorption issues.

Why The Other Options Are Incorrect

B complex: The B vitamins are water-soluble and play roles in energy metabolism, nerve function, and red blood cell production, but they are not related to night vision. Deficiencies in B vitamins may cause symptoms such as fatigue, anemia, or neurological issues, but not difficulty seeing at night.

 D: Vitamin D is important for calcium absorption and bone health, preventing rickets in children and osteomalacia in adults. It does not affect visual function, particularly night vision.

 K: Vitamin K is necessary for blood clotting. A deficiency can lead to prolonged bleeding or bruising, but it does not cause visual disturbances or night blindness.

Summary

The client’s difficulty seeing at night strongly suggests a deficiency in vitamin A (retinol), which is crucial for night vision. Vitamins B, D, and K do not play direct roles in vision, particularly in dark environments.

The correct interventions for a client with suspected pertussis are:

Wear a mask when providing care within 3 ft of the client.

Place a surgical mask on the client if transportation to another department is unavoidable.

Wear a gown when performing care that might result in contamination from secretions.

Detailed Explanations:

Wear a mask when providing care within 3 ft of the client: Pertussis, also known as whooping cough, is transmitted via respiratory droplets. A mask should be worn by healthcare providers when they are within close proximity (3 feet or less) of the patient to prevent the spread of these droplets.

Place a surgical mask on the client if transportation to another department is unavoidable: When transporting a patient with suspected pertussis, a surgical mask should be placed on the patient to prevent the release of respiratory droplets during movement. This helps limit exposure to others and is standard for diseases transmitted via respiratory droplets.

Wear a gown when performing care that might result in contamination from secretions: Pertussis can cause coughing fits that may result in aerosolization of respiratory secretions. A gown is necessary when performing procedures that could result in splashing or contamination with respiratory fluids to protect both the healthcare provider and the environment.

Why the other options are incorrect:

Place the client in a room that has negative air pressure of at least six exchanges per hour: Negative air pressure rooms are required for airborne diseases like tuberculosis or varicella, which spread through tiny airborne particles. Pertussis, however, is spread via respiratory droplets, not airborne particles, so a negative pressure room is not necessary.

Use sterile gloves when handling soiled linens: Sterile gloves are not required for handling soiled linens in the case of pertussis. Standard precautions (non-sterile gloves) should be used when handling potentially contaminated materials, but sterile gloves are unnecessary unless a sterile field is being maintained.

Summary:

For a client with suspected pertussis, it is important to wear a mask when within close proximity to the patient, place a surgical mask on the patient during transport, and wear a gown if exposure to respiratory secretions is possible. Negative air pressure rooms and sterile gloves for handling linens are not required.

 Correct Answer: Folic acid

Explanation

Folic acid (vitamin B9) is essential in early pregnancy to support proper neural tube development. Adequate intake of folic acid before conception and during the first trimester significantly reduces the risk of neural tube defects (NTDs), such as spina bifida and anencephaly. The CDC and other health organizations recommend that women of childbearing age consume at least 400 mcg of folic acid daily to help prevent these birth defects.

Why The Other Options Are Incorrect

 Lutein:

Lutein is an antioxidant that plays a role in eye health, particularly in protecting against age-related macular degeneration. It is not associated with preventing birth defects and is not a recommended supplement for this purpose.

Omega-3 fatty acids:

Omega-3s, especially DHA, support fetal brain and eye development, but they are not linked to preventing birth defects. While beneficial during pregnancy, they do not replace the role of folic acid in neural tube formation.

Vitamin D:

Vitamin D supports bone development, immune function, and overall health in both the mother and fetus. However, it is not specifically associated with reducing the risk of birth defects, particularly neural tube defects.

Summary

Folic acid is the supplement specifically recommended to prevent neural tube defects in neonates when taken before and during early pregnancy. Lutein, omega-3 fatty acids, and vitamin D offer other health benefits but do not reduce the risk of birth defects like folic acid does.

Correct Answers:

Capillary refill less than 3 seconds

Thick skin on the soles of the feet

2+ pulses on the client’s lower extremities

Detailed Explanation of the Correct Answers:

Capillary refill less than 3 seconds

This is an expected finding. It indicates adequate peripheral perfusion and circulatory status. Capillary refill time greater than 3 seconds may indicate circulatory or perfusion issues.

Thick skin on the soles of the feet

This is also expected. The soles of the feet typically develop thicker skin due to constant pressure and friction from standing and walking.

 2+ pulses on the client’s lower extremities

This is a normal and expected pulse strength. Pulses are typically graded on a scale from 0 to 4+, with 2+ considered normal.

Why the Other Options Are Incorrect:

 1+ pitting edema in both feet

Although mild, any pitting edema is an abnormal finding and may suggest fluid retention, venous insufficiency, or other health concerns. It should not be considered an expected result during a general assessment.

 Pale nail beds in one hand

This is abnormal and may indicate localized circulatory issues, anemia, or reduced oxygenation. Nail beds should normally appear pink and symmetrical in both hands.

Summary:

During a comprehensive skin assessment, normal findings include capillary refill under 3 seconds, thickened skin on the soles, and 2+ peripheral pulses. Edema and pallor are considered abnormal and require further evaluation.

Correct Answer: You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling.

Detailed Explanation of the Correct Answer:

This response demonstrates therapeutic communication. It acknowledges the client's feelings without trying to minimize or compare them, and it invites the client to express more. It shows empathy and encourages the client to open up, which is essential in emotional and grief-related situations.

Why the Other Options Are Incorrect:

 It takes time to get over the loss of a loved one.

This response is dismissive. While it may be true that healing takes time, this statement can feel minimizing to the client and does not encourage further discussion or emotional expression.

Why don't you try something to take your mind off your troubles, like watching a funny movie.

This shifts attention away from the client's emotional pain and implies avoidance rather than supporting emotional processing. It may seem insensitive during a time when the client needs to feel heard and validated.

I might not share your exact situation, but I do know what people go through when they deal with a loss.

This is an attempt at empathy, but it turns focus toward generalizations rather than the client's unique experience. It also risks making the conversation about the nurse’s understanding rather than the client’s emotions.

Summary:

The nurse should use therapeutic communication that validates the client’s feelings and encourages expression. The best response is to acknowledge the client's perspective and offer an open invitation to talk.

 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: Cyanosis

Detailed Explanation of the Correct Answer:

 Cyanosis:

Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It is most commonly seen around the lips, fingertips, and nail beds. In this case, the bluish color around the woman's lips suggests that oxygen levels are low, which is a potential complication of cystic fibrosis, a condition that affects respiratory function.

Why the Other Options Are Incorrect:

 Jaundice:

Jaundice refers to a yellow discoloration of the skin and eyes due to elevated bilirubin levels, typically associated with liver dysfunction. It does not cause bluish discoloration.

Pallor:

Pallor refers to an unusual paleness of the skin, often caused by anemia, shock, or poor blood flow. It is not characterized by a bluish hue.

Erythema:

Erythema is redness of the skin resulting from increased blood flow, commonly seen with inflammation, fever, or infection. It does not appear blue or purple.

Summary:

A bluish color around the lips indicates cyanosis, which is a sign of inadequate oxygenation—a serious concern in patients with cystic fibrosis.