ATI NUR 130 Final Exam

Correct Answers:

Maintain airflow rate greater than 12 air exchanges/hr.

Open drapes during the daytime.

Listen to the patient's interests

Explanation of Correct Answers:

Maintain airflow rate greater than 12 air exchanges/hr

This is a standard requirement for protective environments (also called protective isolation). Positive-pressure rooms with HEPA filtration and high air exchange rates help protect immunocompromised patients by minimizing exposure to airborne microorganisms.

Open drapes during the daytime

Allowing natural light and maintaining a normal day-night cycle supports the patient’s mental and emotional well-being while in isolation.

Listen to the patient's interests

Supporting emotional and psychological health is a key part of caring for patients in isolation. Understanding their interests helps with individualized care and reduces the negative emotional impact of isolation.

Explanation of Incorrect Answers:

a. Wear an N95 respirator when entering the patient's room

N95 respirators are used for airborne precautions (e.g., tuberculosis), not for protective environments. In protective isolation, the goal is to protect the patient from us, not vice versa.

Place in special room with negative-pressure airflow

Negative-pressure rooms are used for airborne isolation (to contain pathogens). Protective environments require positive-pressure rooms to prevent outside contaminants from entering.

Place dried flowers in a plastic vase

Dried or fresh flowers can harbor mold or bacteria and are typically not allowed in protective environments due to the risk of infection for immunocompromised patients.

Summary:

The nurse should maintain high airflow exchange (b), support the patient's emotional health (d, e), and avoid unnecessary exposure to possible contaminants.

Correct Answer: Elevated blood sugar levels

Detailed Explanation of the Correct Answer:

The primary cause of diabetic foot complications—including neuropathy (nerve damage) and peripheral vascular disease (PVD)—is chronic elevated blood sugar levels. Prolonged hyperglycemia damages blood vessels and nerves over time. This damage reduces sensation in the feet (neuropathy), which prevents individuals from feeling injuries or pressure, and impairs circulation (PVD), which restricts blood flow needed for healing. As a result, even minor injuries can progress into serious infections or ulcers, and healing becomes significantly delayed. This combination of nerve damage and reduced blood flow is what makes diabetic foot complications so dangerous and common.

Explanation of Incorrect Options:

High protein intake – While diet is important in diabetes management, high protein intake is not directly linked to foot complications. In fact, adequate protein supports tissue repair and healing.

Elevated blood pressure – High blood pressure can contribute to cardiovascular disease and worsen complications in diabetes, but it is not the primary cause of neuropathy or PVD in diabetic foot complications.

Strong immune system – A strong immune system helps protect against infections and is beneficial in managing wounds. Diabetic patients often have impaired immune function, which contributes to complications. Thus, a strong immune system is not a cause of complications but a protective factor.

Summary:

The primary driver of diabetic foot complications is elevated blood sugar levels, which damage nerves and blood vessels, leading to neuropathy and peripheral vascular disease. Other factors like high protein intake, high blood pressure, or a strong immune system are not direct causes of these specific foot complications.

Correct Answer: Thermal or radiation energy

Explanation of Correct Answer:

Thermal or radiation energy

Sunburns, scald burns, and radiation burns all involve injury caused by external sources of energy:

Sunburn results from ultraviolet (UV) radiation exposure from the sun.

Scald burns are caused by thermal energy from hot liquids or steam.

Radiation burns are typically caused by ionizing radiation (e.g., from radiation therapy or high-dose exposure). All three types lead to damage of the epidermis and possibly deeper tissues, with symptoms like redness, pain, blistering, and, in severe cases, tissue necrosis.

Explanation of Incorrect Options:

Bacterial infection

While burns can increase susceptibility to bacterial infection due to a compromised skin barrier, the initial cause of injury is not bacterial. Infection is a potential complication, not a common factor.

Prolonged exposure to water

This may cause skin maceration or other non-burn-related conditions, but it is not a factor in the cause of sunburn, scalds, or radiation burns. Scalding involves hot water, but temperature, not moisture, is the damaging agent.

Allergic reaction

Allergic reactions involve the immune system responding to allergens and are unrelated to thermal or radiation burns. While a sunburn may sometimes resemble a rash, it is not caused by an allergic mechanism.

Summary:

The unifying cause of sunburns, scald burns, and radiation burns is thermal or radiation energy, which directly damages the skin and underlying tissues through heat or radiation exposure.

Correct Answer: Hemoglobin

Detailed Explanation of the Correct Answer:

Hemoglobin is a critical lab value to assess when evaluating risk for pressure injuries because it reflects the blood’s oxygen-carrying capacity. Adequate tissue oxygenation is essential for maintaining healthy skin and supporting wound healing. Low hemoglobin levels (anemia) can lead to poor tissue perfusion, which increases the risk of tissue breakdown and pressure injuries. Therefore, monitoring hemoglobin helps the nurse evaluate if the patient has sufficient oxygen delivery to tissues to maintain skin integrity and support repair processes.

Explanation of Incorrect Options:

Xerosis – This refers to abnormally dry skin, not a laboratory study. While xerosis can affect skin health, it is not a lab value the nurse would check.

Suspensions – This is a form of medication delivery, not a lab test. It has no relevance to lab evaluation for pressure injury risk.

Hydrophilic – This term refers to substances that attract water, and it is not a lab value. It is unrelated to assessing pressure injury risk via laboratory studies.

Summary:

When evaluating risk for pressure injuries, the nurse should check hemoglobin to ensure adequate oxygenation and perfusion of tissues. Low hemoglobin levels can compromise skin integrity, increasing the patient’s risk for developing pressure ulcers. The other options listed are not laboratory values and do not assist in this type of assessment.

Correct Answer: Hyperthermia occurs when the body cannot reduce heat production

Labeled and Detailed Explanation for the Correct Answer:

Hyperthermia occurs when the body cannot reduce heat production:

Hyperthermia is a condition where the body’s heat loss mechanisms are overwhelmed, leading to an uncontrolled rise in body temperature. This occurs without a change in the hypothalamic set point, unlike fever. In hyperthermia, the body continues producing heat (due to exertion, environmental heat, or impaired cooling mechanisms) faster than it can dissipate it, leading to dangerous elevation in temperature. This principle is essential for nurses to understand in order to differentiate hyperthermia from fever and respond appropriately with cooling measures.

Explanation of Why the Incorrect Options Are Wrong:

 Hyperthermia and fever are the same thing:

This is incorrect. Although both involve elevated body temperatures, the mechanisms differ. Fever is a regulated response to infection where the hypothalamic set point is raised, while hyperthermia involves an unregulated rise in body temperature without a change in the set point.

 Hyperthermia is an upward shift in the set point:

This is false. An upward shift in the hypothalamic set point is characteristic of fever, not hyperthermia. In hyperthermia, the set point remains normal, but the body overheats because it can't dissipate heat effectively.

Hyperthermia results from a reduction in thermoregulatory mechanisms:

This is partially true, but not the most accurate or complete explanation for hyperthermia in this context. While impaired thermoregulation can contribute, the main principle is that the body cannot balance heat production and loss, particularly increased heat production.

Summary:

Hyperthermia is a dangerous rise in body temperature that occurs when the body fails to dissipate heat effectively, not due to a change in the brain's temperature set point. It is not the same as fever, which is a controlled physiological response. The correct answer is c. Hyperthermia occurs when the body cannot reduce heat production.

Correct Answer: Insert a spare tracheostomy with the obturator.

Detailed Explanation of the Correct Answer:

Insert a spare tracheostomy with the obturator.

This is the first and most critical action. When a tracheostomy tube becomes dislodged, reestablishing the airway is the immediate priority. Most tracheostomy care protocols require a spare tracheostomy tube (of the same size or one size smaller) and obturator to be kept at the bedside for emergencies. The nurse should immediately insert the spare tube using the obturator, remove the obturator once placed, and assess for breath sounds and effective air exchange.

Why the Incorrect Options Are Wrong:

Press the emergency response button.

While this is an appropriate action if the nurse is unable to reinsert the tube or the patient is in distress, it is not the first step. The priority is to attempt immediate reinsertion of the tube to prevent hypoxia.

Manually occlude the tracheostomy with sterile gauze.

Occluding the stoma with gauze could block airflow through the natural airway and should only be done if the trach cannot be reinserted and the patient needs to breathe through the nose/mouth. It’s a temporary backup measure, not the first choice.

Place a face mask delivering 100% oxygen over the nose and mouth.

This is only appropriate if the nurse cannot reinsert the trach and must begin ventilating the patient through the mouth/nose. However, many patients with tracheostomies cannot effectively ventilate through their upper airway, so this would not be reliable as a first intervention.

Summary:

In the event of accidental tracheostomy dislodgement, the priority is to immediately reinsert a spare tracheostomy tube using the obturator to re-establish the airway. All other options are secondary or supportive if reinsertion fails or is delayed.

Correct Answer: Immobility

Detailed Explanation of the Correct Answer:

Immobility is the primary factor contributing to the development of pressure injuries in patients with impaired sensory perception. When patients cannot feel discomfort or pain, they may not recognize the need to change position. As a result, they remain in one position for too long, leading to sustained pressure on certain areas of the body, particularly over bony prominences. This prolonged pressure reduces capillary blood flow, causing ischemia, tissue damage, and eventually pressure injuries.

Patients with conditions such as spinal cord injuries, advanced diabetes with neuropathy, or stroke often have decreased sensation and rely on caregivers or regular repositioning to prevent skin breakdown.

Explanation of Incorrect Options:

Increased Moisture – While moisture can weaken skin integrity and contribute to maceration, it is not the primary factor in pressure injury development related to impaired sensory perception. It is more directly associated with incontinence-related skin issues.

Friction and Shear – Friction and shear are mechanical forces that can exacerbate skin breakdown, especially during repositioning or movement. However, they are secondary factors and not specifically tied to sensory perception loss.

Decreased Tissue Perfusion – This is an important contributing factor in pressure injury development overall, but in the context of impaired sensory perception, immobility is more directly linked, as the patient cannot feel the need to move or shift pressure points.

Summary:

Patients with impaired sensory perception are at greatest risk of developing pressure injuries due to immobility, which leads to unrelieved pressure on the skin. While other factors like moisture, friction, and perfusion affect skin integrity, immobility is the primary concern in this specific context.

Correct Answer: Wound VAC dressing

Detailed Explanation of the Correct Answer:

Wound VAC dressing

Wound VAC (Vacuum-Assisted Closure) dressing is a treatment method that uses negative pressure to promote wound healing. This therapy involves placing a foam dressing in the wound, sealing it with an adhesive drape, and connecting it to a vacuum pump that applies continuous or intermittent suction. The negative pressure helps to:

Remove excess exudate and infectious material

Reduce edema (swelling)

Draw the edges of the wound together

Stimulate blood flow and the formation of granulation tissue

Wound VAC is especially beneficial for complex or non-healing diabetic foot ulcers.

Why the Other Options Are Incorrect:

Debridement – This is the removal of necrotic or infected tissue to promote healing but does not involve negative pressure. It's often used before or alongside VAC therapy.

Surgery – Surgical intervention may be necessary in severe cases (e.g., to remove infected bone or tissue), but it is not a method of applying negative pressure.

Hyperbaric oxygen therapy – This involves breathing 100% oxygen in a pressurized chamber, which enhances oxygen delivery to tissues and aids healing. It does not involve negative pressure.

Summary:

Wound VAC dressing is a specialized therapy that uses negative pressure to accelerate the healing of diabetic foot ulcers by improving circulation, removing fluids, and promoting tissue growth.

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.