ATI NUR 130 Final Exam

Correct Answer: Temperatures vary depending on the route used

Correct Answer Explanation:

Temperatures vary depending on the route used

The route of temperature measurement affects the actual reading. Different body sites provide slightly different temperature values due to their proximity to core temperature and local environmental factors. For example, rectal temperatures are generally higher than oral, while axillary temperatures are typically lower. Because of these variations, it is essential for the nurse to document both the temperature value and the route used so that it can be accurately interpreted by other healthcare providers.

Explanation of Incorrect Options:

Temperatures are readings of core measurements

Not entirely accurate. Not all temperature routes reflect core body temperature. Rectal and temporal artery temperatures are closer to core values, but oral and axillary readings can vary significantly. Therefore, the route still must be documented.

Rectal temperatures are cooler than when taken orally

Incorrect. Rectal temperatures are typically about 0.9°F (0.5°C) higher than oral readings, not cooler.

Axillary temperatures are higher than oral temperatures

Incorrect. Axillary temperatures are usually about 0.9°F (0.5°C) lower than oral temperatures, not higher.

Summary:

The nurse documents both the temperature value and the route because readings vary depending on where the temperature is taken. This documentation ensures accurate comparison and clinical interpretation.

Correct Answer: Unintentional, open, acute

Detailed Explanation of the Correct Answer:

d) Unintentional, open, acute

This option best describes a traumatic wound resulting from an accident:

Unintentional: The wound was not planned or created under sterile conditions, as would be the case with surgical wounds.

Open: The skin barrier is broken, exposing tissue underneath, which increases the risk of contamination and infection.

Acute: The wound occurs suddenly and requires immediate medical attention. It typically follows a predictable healing process if properly managed.

Why the Other Options Are Incorrect:

Intentional, open, chronic

Intentional wounds are typically surgical or therapeutic in nature.

Chronic wounds develop over time and often result from underlying conditions like diabetes or poor circulation—not sudden trauma.

Unintentional, closed, acute

While the wound may be unintentional and acute, the description of closed does not apply to a traumatic wound that visibly breaks the skin.

Intentional, closed, chronic

This is inaccurate on all fronts for a trauma-related wound. Traumatic wounds are not intentional, and they are neither typically closed nor chronic at the outset.

Summary:

A traumatic accident that results in a wound requiring immediate care is best described as an unintentional, open, acute wound. This classification highlights the accidental nature of the injury, the disruption of the skin barrier, and the need for prompt medical intervention.

Correct Answer: Regular foot inspections

Detailed Explanation of the Correct Answer:

Regular foot inspections

This is crucial for preventing diabetic foot ulcers. People with diabetes often suffer from peripheral neuropathy, which reduces sensation in the feet. Because of this, they might not feel pain from injuries, blisters, or pressure sores. Regular foot inspections—either by the patient or a caregiver—allow early detection of wounds, redness, or signs of infection, enabling prompt treatment before complications develop.

Why the Other Options Are Incorrect:

Maintaining elevated blood sugar levels

This is incorrect because high blood sugar damages blood vessels and nerves, impairing circulation and sensation. This increases the risk Regular use of good-fitting shoes

While important, this is not the only crucial factor. It helps prevent injuries but doesn’t replace the need for inspection.

Avoiding any foot movement

This is incorrect because immobilization can reduce circulation and lead to muscle atrophy and stiffness. Controlled movement and regular foot care are part of prevention strategies.

Summary:

The primary factor for preventing diabetic foot ulcers is regular foot inspections, as it ensures early identification of problems that might otherwise go unnoticed due to neuropathy.

Correct Answer: Pressure ulcer

Explanation of Correct Answer:

Pressure ulcer

A pressure ulcer (also known as a pressure injury or bedsore) is caused by prolonged pressure on the skin and underlying tissues, especially over bony prominences like the sacrum, heels, elbows, and hips. This sustained pressure disrupts capillary blood flow (perfusion), leading to ischemia (lack of oxygen), tissue breakdown, and necrosis. Individuals who are immobile, malnourished, or have poor circulation are at higher risk.

Explanation of Incorrect Answers:

Surgical incision

Incorrect. A surgical incision is a planned, controlled injury created by a surgeon during an operation. It is not caused by pressure but rather by cutting through tissue using sterile technique for medical intervention.

Thermal injury

Incorrect. A thermal injury results from exposure to extreme heat or cold, such as burns or frostbite. It is not caused by pressure or impaired perfusion.

Immunologic reaction

Incorrect. Immunologic reactions are responses of the immune system to allergens, pathogens, or other antigens. These include conditions like eczema, contact dermatitis, or autoimmune disorders. They are not caused by prolonged pressure.

Summary:

A pressure ulcer is the result of prolonged pressure on tissues, leading to disruption of blood flow (perfusion), which causes tissue damage or death. This distinguishes it from other injury types like incisions, burns, or immune responses.

Correct Answer: Utilize SBAR to notify the primary health care provider.

Correct Answer Explanation:

Utilize SBAR to notify the primary health care provider.

This is the most appropriate first action because the patient is showing early signs of a surgical site infection (SSI): redness, purulent drainage, tenderness, mild fever (100.5° F), and an elevated white blood cell count (WBC 10,500/mm³). Using SBAR (Situation, Background, Assessment, Recommendation) allows the nurse to communicate the patient's condition clearly and efficiently to the provider so that timely medical intervention (e.g., wound culture, antibiotic therapy) can be initiated. Prompt reporting is crucial in preventing worsening infection.

Explanation of Incorrect Options:

Plan to change the surgical dressing during the shift.

Incorrect. While dressing changes are important, planning alone without notifying the provider delays potential treatment. Infection signs must be addressed immediately, not simply managed passively.

Reevaluate the temperature and white blood cell count in 4 hours.

Incorrect. Monitoring is useful, but waiting 4 hours before acting could allow the infection to progress. The signs of infection are already present and warrant immediate attention.

Check to see what solution was used for skin preparation in surgery.

Incorrect. Although a reaction to Betadine (povidone-iodine) is possible, the current signs—purulent drainage and fever—suggest infection rather than an allergic reaction. The priority is treating the current clinical findings, not reviewing surgical prep details first.

Summary:

The patient has clear indicators of a possible surgical site infection, which requires timely reporting to the healthcare provider for further diagnostic and therapeutic actions. While dressing changes, ongoing monitoring, and reviewing prep solutions may be appropriate secondary actions, the first priority is to notify the provider using SBAR communication.

Correct Answer: Complicated grief

Detailed Explanation of the Correct Answer:

Complicated grief

Complicated grief is a prolonged, intense, and disabling form of grief that interferes with normal functioning. It often persists well beyond the expected time frame for grieving (in this case, 2 years after the loss). The nurse is showing clear signs of emotional and functional impairment, including breakdowns at work and at home, which is consistent with complicated grief. People experiencing this form of grief may feel stuck, unable to move forward or cope with daily life.

Why the Incorrect Options Are Wrong:

Normal grief

Normal grief typically includes a range of emotional responses that gradually diminish over time and allow the person to return to functional living. Since the nurse is still emotionally overwhelmed and her functioning has declined 2 years after the loss, this exceeds the typical pattern and time frame of normal grief.

 Perceived grief

Perceived grief refers to a loss that is not outwardly recognized by others (such as loss of independence or job). The loss in this scenario (a spouse) is a recognized and tangible loss, making this term inapplicable.

Disenfranchised grief

Disenfranchised grief is experienced when a loss cannot be openly acknowledged or publicly mourned, such as the death of a secret partner or a miscarriage not shared with others. The nurse’s grief over her spouse, a socially recognized loss, does not meet the definition of disenfranchised grief.

Summary:

The female nurse is struggling with intense and prolonged emotional pain, well past the usual grief period, and it is interfering with her daily life and work. This pattern reflects complicated grief, not normal, perceived, or disenfranchised grief.

Correct Answer: Bullae

Explanation of the Correct Answer:

c) Bullae are large, fluid-filled blisters that are usually greater than 5 mm in diameter. They form between layers of the skin due to injury, infection, or certain skin disorders (e.g., burns, bullous pemphigoid). Bullae contain serous or serosanguineous fluid and may occur alone or in clusters.

Why the Other Options Are Incorrect:

Hydrophilic

This term means “water-attracting” or capable of absorbing water. It refers to a property of substances or materials, not a type of lesion or blister.

Pressure Injury

A pressure injury (previously called a pressure ulcer or bedsore) is localized damage to the skin and underlying tissue, usually over a bony area, caused by prolonged pressure or shear. While open sores or ulcers can occur, they are not classified as fluid-filled blisters like bullae.

Xerosis

Xerosis means abnormal dryness of the skin, which is a common condition, especially in older adults. It is unrelated to fluid-filled blisters.

Summary:

Bullae are the correct term for large, fluid-filled blisters, making option c the most accurate answer.

Correct Answer: Touching clean protective eyewear

Correct Answer Explanation:

Touching clean protective eyewear

This indicates a break in sterile technique. Although the eyewear itself may appear clean, it is not sterile. Once a nurse is scrubbed, gowned, and gloved in sterile attire, they must only touch sterile objects. Touching non-sterile items like eyewear—even if considered "clean"—contaminates the sterile gloves, and therefore breaks sterility.

Explanation of Incorrect Options:

Standing with hands above waist area

Incorrect. This is correct sterile technique. The sterile field is maintained at or above waist level. Keeping hands above the waist ensures they remain in the sterile zone and are less likely to touch contaminated areas.

Accepting sterile supplies from the surgeon

Incorrect. It is acceptable and expected to receive sterile supplies as long as they are passed correctly (e.g., presented in a sterile manner). Both parties must be sterile or maintain sterile transfer technique.

Staying with the sterile table once it is open

Incorrect. This is proper sterile technique. Once a sterile field is opened, it must be attended continuously to ensure it remains uncontaminated. Leaving it unattended would break sterility, but staying with it does not.

Summary:

The nurse breaks sterile technique by touching clean but non-sterile eyewear while wearing sterile gloves and gown. Once in sterile attire, the nurse must only interact with sterile objects to prevent contamination.

Correct Answer: All of the above

Explanation of the Correct Answer:

All of the above

Impaired tissue integrity can significantly impact multiple physiological and functional aspects of health, including:

Fluid balance and infection protection

The skin and mucous membranes act as a barrier to prevent excessive fluid loss.

When this barrier is broken (e.g., wounds, ulcers, burns), the body becomes vulnerable to dehydration and infection, as pathogens can easily enter.

Thermoregulation and elimination

The skin helps regulate body temperature through sweat glands and blood vessel dilation/constriction.

Damage to skin can impair this regulation, leading to difficulty in maintaining stable body temperature.

Tissue damage, especially in the perineal area, can interfere with normal elimination functions (e.g., urinary incontinence, wound contamination from feces/urine).

Pain perception and mobility

Tissue damage often activates pain receptors, resulting in increased pain perception.

Wounds, swelling, or pressure injuries may cause discomfort or physical restrictions, limiting mobility and affecting daily activities.

Why the Incorrect Options Are Incomplete:

Fluid balance and infection protection

– This is correct but does not address the full scope of how tissue integrity affects health.

Thermoregulation and elimination

– Again, accurate, but only part of the broader impact.

Pain perception and mobility

– Valid but does not consider other systemic consequences of impaired tissue integrity.

Summary:

Impaired tissue integrity affects fluid balance, infection defense, thermoregulation, elimination, pain, and mobility. Therefore, the most comprehensive and correct answer is d. All of the above.