ATI NUR 130 Final Exam

Correct Answer: All of the above

Explanation of the Correct Answer:

All of the above

Tissue integrity is influenced by multiple interrelated concepts, and all the options listed are connected:

Pain perception: Impaired tissue integrity often results in pain due to nerve exposure or inflammation, making pain management a crucial part of care.

Sensory perception: A loss or reduction in sensory perception (e.g., in patients with diabetic neuropathy or spinal cord injury) can increase the risk of pressure injuries or burns because the patient may not feel discomfort that would normally prompt a change in position or avoidance of harm.

Fluid and electrolyte balance: The skin plays a vital role in fluid retention. When tissue integrity is compromised (e.g., in burns or open wounds), it can lead to fluid loss, electrolyte imbalance, and complications like dehydration and hypovolemia.

Why the Other Options Are Incorrect Individually:

While each of the individual options (a, b, and c) is indeed related to tissue integrity, choosing only one would be an incomplete answer. The question asks for the concept most closely related, and since all three are closely interrelated, “all of the above” is the most accurate choice.

Summary:

Tissue integrity is interwoven with pain perception, sensory perception, and fluid and electrolyte balance, all of which influence risk factors, symptoms, and treatment outcomes in patients with skin or mucosal damage.

Correct Answer: Cheilitis

Detailed Explanation of the Correct Answer:

Cheilitis is the medical term for inflammation of the lips. It typically presents with symptoms such as dryness, redness, swelling, cracking, or soreness at the corners or on the surface of the lips. It can result from various causes, including sun exposure, allergic reactions, irritants (such as lip licking or cosmetics), infections (like yeast or bacteria), nutritional deficiencies (especially B vitamins or iron), or underlying chronic conditions such as eczema. Treatment usually involves addressing the underlying cause and providing moisturizing or medicated lip care.

Explanations for the Incorrect Options:

Carbuncle refers to a cluster of boils (furuncles) connected under the skin, usually caused by a bacterial infection, particularly Staphylococcus aureus. It typically occurs on the back of the neck, shoulders, or thighs and does not involve inflammation of the lips.

Lichenification describes the thickening and hardening of the skin due to chronic scratching or rubbing. It’s often seen in chronic eczema or dermatitis but does not pertain to the lips specifically.

Hydrophobic is a scientific term meaning “water-repelling.” It’s used to describe substances that do not mix with or absorb water. It is unrelated to any type of inflammation or skin condition.

Summary:

Cheilitis is the correct term for lip inflammation, often characterized by chapped, dry, or cracked lips. The other options refer to unrelated skin conditions or properties.

Correct Answer: I should report if I see continuous bubbling in the water-seal chamber.

Explanation of the Correct Answer:

I should report if I see continuous bubbling in the water-seal chamber.

This statement shows successful learning. Continuous bubbling in the water-seal chamber typically indicates an air leak, which can compromise the function of the chest tube and patient safety. The nurse should assess the source of the air leak and notify the provider.

Why the Other Options Are Incorrect:

I should clamp the chest tube when giving the patient a bed bath.

Clamping a chest tube is contraindicated except in very specific situations (e.g., when checking for air leaks or briefly changing the drainage system). Clamping can lead to tension pneumothorax. Bathing does not require clamping.

I should strip the drains on the chest tube every hour to promote drainage.

Stripping the tube (squeezing and dragging it) can create dangerous negative pressure, potentially damaging lung tissue. This practice is not recommended unless specifically ordered and done with great caution.

I should notify the health care provider first, if the chest tube becomes dislodged.

This is incorrect because the first action is to immediately cover the site with a sterile occlusive dressing (e.g., petroleum gauze), then notify the provider. Prompt action helps prevent air from entering the pleural space and causing a pneumothorax.

Summary:

The student correctly understands that continuous bubbling in the water-seal chamber is abnormal and should be reported, indicating successful learning. Other actions listed are unsafe or demonstrate a misunderstanding of proper chest tube management.

Correct Answer:  Sleeping on two to three pillows at night

Labeled and Detailed Explanation for the Correct Answer:

a. Sleeping on two to three pillows at night – This is the best intervention to address a short-term goal for a patient experiencing fatigue related to ineffective breathing. Elevating the upper body by sleeping on multiple pillows can help improve lung expansion and oxygenation during sleep, which can reduce fatigue caused by poor breathing. It is immediately implementable, does not require a drastic lifestyle change, and provides symptomatic relief while longer-term interventions are also considered.

Explanations for Each Incorrect Option:

 Limiting the diet to 1500 calories a day – While important for long-term weight loss and overall health, this dietary intervention does not directly or immediately improve breathing or fatigue. It is a long-term goal, not a short-term intervention.

Running 30 minutes every morning – This would be unrealistic and unsafe for an obese patient who is already fatigued and experiencing breathing difficulties. It is not a short-term achievable goal for this clinical situation.

 Stopping smoking immediately – Smoking cessation is essential for overall respiratory health, but it may take time for the lungs to recover. Therefore, while important, it does not provide immediate relief of breathing-related fatigue and is better considered a long-term health goal.

Summary:

The most appropriate short-term intervention for an obese patient with fatigue due to ineffective breathing is sleeping on two to three pillows at night, as it provides immediate respiratory support. Other options like dieting, exercising, and smoking cessation are important long-term strategies but do not address the immediate goal of improving fatigue related to breathing difficulty.

Correct Answer: Relieving pressure and promoting blood flow

Detailed Explanation of the Correct Answer:

The key goal in preventing pressure injuries is to relieve pressure on vulnerable areas of the body and promote adequate blood flow to tissues. Pressure injuries (also known as pressure ulcers or bedsores) occur when sustained pressure reduces or cuts off circulation to an area of skin and underlying tissue, typically over bony prominences such as the sacrum, heels, and elbows. By repositioning patients regularly, using pressure-relieving devices (e.g., special mattresses or cushions), and encouraging mobility when possible, nurses can help maintain tissue perfusion and prevent tissue breakdown.

Explanation of Incorrect Options:

Increasing friction and shear – This is actually a risk factor for pressure injury development. Friction and shear can damage skin and deeper tissues, making pressure injuries more likely, not less.

Promoting pressure injury healing – While healing is important after a pressure injury has developed, the question focuses on prevention. The goal in prevention is to avoid the injury altogether.

Reducing mobility and activity – This would increase the risk of pressure injuries. Immobility is one of the primary contributing factors to pressure injury development, especially in hospitalized or bed-bound patients.

Summary:

The most effective preventive strategy for pressure injuries is to relieve pressure and ensure proper blood flow to at-risk areas. This helps maintain skin and tissue integrity by supplying oxygen and nutrients while removing waste products, thereby preventing ischemia and breakdown.

Correct Answer: It is important to do breathing exercises every hour to prevent atelectasis.

Detailed Explanation of the Correct Answer

It is important to do breathing exercises every hour to prevent atelectasis.

This statement is correct and indicates understanding. Atelectasis is the collapse of alveoli, often due to hypoventilation, pain, or immobility postoperatively or during illness. Breathing exercises such as incentive spirometry, deep breathing, and coughing help to re-expand collapsed alveoli, improve ventilation, and prevent atelectasis. Frequent use (e.g., every hour while awake) is recommended, especially after surgery.

Why the Incorrect Options Are Wrong:

Atelectasis affects only those with chronic conditions such as emphysema.

Incorrect. While individuals with chronic lung conditions are at higher risk, anyone, especially postoperative patients or those on bed rest or shallow breathing, can develop atelectasis. It is not limited to those with chronic lung disease.

If I develop atelectasis, I will need a chest tube to drain excess fluid.

Incorrect. A chest tube is used for conditions like pneumothorax or pleural effusion, not atelectasis. Atelectasis is caused by airway obstruction or hypoventilation, not fluid accumulation in the pleural space.

Hyperventilation will open up my alveoli, preventing atelectasis.

Incorrect. Hyperventilation, which leads to excessive exhalation of CO₂, can cause dizziness and is not the recommended technique for reopening alveoli. Instead, controlled deep breathing with incentive spirometry is more effective and safer for preventing atelectasis.

Summary:

Atelectasis is preventable with regular deep breathing exercises that keep the alveoli open. The best understanding is shown by the patient who commits to hourly breathing exercises, which is key to prevention. Other options reflect misunderstandings about who can be affected or how it’s managed.

Correct Answers:

Observations of wound healing

Daily blood pressure measurements

Findings of respiratory rate and depth

 Patient's subjective report of feelings about a new diagnosis of cancer

Detailed Explanation of Each Correct Answer:

Observations of wound healing

This is an objective evaluative measure. The nurse visually examines the wound to assess whether the care plan is effective in promoting healing.

Daily blood pressure measurements

This is a quantitative, objective measure used to evaluate whether interventions (e.g., medication, lifestyle changes) are helping control blood pressure.

Findings of respiratory rate and depth

This is another objective assessment that helps determine the effectiveness of respiratory interventions such as breathing treatments or oxygen therapy.

Patient's subjective report of feelings about a new diagnosis of cancer

Subjective data—what the patient says or feels—is an important evaluative measure when assessing emotional and psychological responses to care, especially for new diagnoses.

Why the Incorrect Option Is Wrong:

Completion of nursing interventions

This reflects nursing action, not patient response. While it’s important to document what was done, evaluation focuses on how the patient responded to the care provided—not whether tasks were completed.

Summary:

Evaluative measures focus on the patient's response to care, both objective (e.g., wound healing, vital signs) and subjective (e.g., emotional responses). The correct evaluative measures are a, b, c, and e.

Correct Answer: Skin self-assessment for melanoma using the ABCDE mnemonic

Explanation of the Correct Answer:

Skin self-assessment for melanoma using the ABCDE mnemonic

This is a classic example of secondary prevention, which focuses on early detection and prompt intervention to prevent progression of disease or complications. Teaching individuals to perform skin self-assessments using the ABCDE mnemonic (Asymmetry, Border, Color, Diameter, Evolving) helps detect melanoma and other skin cancers in their early stages, when treatment is more effective and outcomes are better.

Why the Other Options Are Incorrect:

Antibiotic therapy for skin infections

This is a tertiary prevention measure. It is used after an infection has already occurred and aims to manage or cure the infection and prevent further complications.

Surgical excision of suspicious skin lesions

This is also a tertiary prevention strategy. It involves treatment of an existing lesion to remove cancerous or potentially cancerous tissue and prevent spread.

Skin hydration with emollients

This is a primary prevention measure. Maintaining skin hydration with emollients helps prevent skin breakdown, dryness, and irritation, which in turn helps preserve tissue integrity.

Summary:

Secondary prevention includes screening and early detection of health issues to enable timely treatment. Skin self-assessment using the ABCDE mnemonic is a key example, aimed at identifying skin cancer signs early for better prognosis and treatment outcomes.

Correct Answer:

2, 4, 6, 1, 5, 3

Detailed Explanation of the Correct Answer:

The chain of infection is a sequence of events that allows infection to spread from one source to another. Breaking any link in this chain can help prevent the spread of infection. Here is the correct order:

Step 1 – Infectious Agent or Pathogen (2):

This is the microorganism that causes disease (e.g., bacteria, viruses, fungi).

Step 2 – Reservoir (4):

The place where the pathogen lives and multiplies. This could be a person, animal, water, or equipment.

Step 3 – Portal of Exit (6):

The path the pathogen takes to leave the reservoir (e.g., respiratory tract, GI tract, blood).

Step 4 – Mode of Transmission (1):

How the pathogen is transferred from the reservoir to a susceptible host (e.g., direct contact, airborne, droplets, contaminated surfaces).

Step 5 – Portal of Entry (5):

The way the pathogen enters the new host (e.g., broken skin, mucous membranes, respiratory or urinary tracts).

Step 6 – Susceptible Host (3):

A person who is vulnerable to infection due to factors like age, immune status, or chronic disease.

Why the Other Options Are Incorrect:

Option a. 3, 2, 4, 1, 5, 6: Starts with a susceptible host, which is the last step, not the first.

Option b. 1, 3, 5, 4, 6, 2: Begins with the mode of transmission and host before identifying the infectious agent or reservoir—this skips logical cause-effect order.

Option c. 4, 2, 1, 6, 3, 5: Begins with the reservoir before the pathogen; while these are closely related, the infectious agent comes first. Also misorders other steps.

Summary:

The correct sequence of the chain of infection is: Infectious agent → Reservoir → Portal of exit → Mode of transmission → Portal of entry → Susceptible host

Knowing this sequence helps nurses identify and break the chain to prevent infections in clinical settings.