Nur 215 Medical Surgical 1

Correct Answer:

“I can stop using the medication if my skin looks worse.”

Explanation:

Fluorouracil often causes the skin to look worse before it gets better. Redness, scaling, and inflammation are expected effects of the medication as it destroys precancerous or cancerous cells. Stopping the medication early due to worsening appearance would reduce its effectiveness. Patients need to understand this and complete the prescribed course unless otherwise directed by the healthcare provider.

Why Other Options Are Wrong:

“I need to avoid being in the sun while on this medication.”

This is correct and important. Fluorouracil increases photosensitivity, and sun exposure can worsen irritation and damage.

“I will apply the medication only to the affected areas.”

This is appropriate, as fluorouracil should not be applied to healthy skin. Applying only to the treatment area limits unnecessary irritation.

“I will wash my hands before and after applying the medication.”

This is also correct. It prevents accidental transfer of the medication to other parts of the body or to other individuals.

Correct Answer:

A patient who has been newly diagnosed with diabetes

A patient who has had vomiting and diarrhea for several days and lost 12 pounds

The patient who has paralysis and unable to move in the bed

A roofer who spends a lot of time outdoors

Explanation:

Patients at risk for skin alteration often have underlying conditions or exposures that compromise skin integrity. Diabetic patients are at increased risk due to impaired circulation and sensation. Dehydration from vomiting and diarrhea affects skin turgor and resilience. Immobility, as seen in paralyzed patients, leads to pressure injuries due to sustained pressure and poor circulation. Roofers experience prolonged sun exposure and sweat buildup, both of which can weaken skin and increase the risk of breakdown.

Why Other Option Is Wrong:

The patient who had numbness in the right arm that resolved several hours ago

Transient numbness without lasting sensory impairment or immobility does not significantly raise the risk of skin breakdown. Once sensation returns, normal skin protection mechanisms are restored.

Correct Answer:

Dilutes urine and often flushes out bacteria before colonization.

Explanation:

Increasing fluid intake during a UTI helps dilute the urine, which can reduce irritation of the urinary tract and assist in flushing out bacteria before they can adhere to the uroepithelial lining and colonize. This reduces the bacterial load and supports the body’s immune defense. Adequate hydration is a simple but effective non-pharmacologic measure to support treatment and reduce symptom severity. Encouraging patients to drink fluids is standard patient education in UTI care.

Why Other Options Are Wrong:

Creatinine levels are more stable but unpredictably useful.

This is misleading. While hydration may influence creatinine levels, the statement is vague and unrelated to UTI-specific benefits. Stability of creatinine isn’t the primary goal or benefit of fluid intake during a urinary tract infection, making this choice incorrect.

Kidneys are less irritable, but bacteria has time to colonize and multiply.

This is inaccurate. While adequate fluids can reduce irritation, increased urination actually helps prevent bacterial colonization. This option incorrectly suggests that hydration delays bacterial clearance, which contradicts the purpose of fluid therapy in UTIs.

Hydration status is not beneficial but may help if combined with high caloric intake.

This is incorrect and misleading. Hydration is indeed beneficial independently of caloric intake, especially in flushing bacteria from the urinary tract. Caloric intake does not significantly affect the flushing or dilution of urine in UTI management, making this choice factually wrong.

Correct Answer:

Compare symmetric parts.

Explanation:

During a physical assessment of the skin, nurses should compare symmetrical body parts to detect differences or abnormalities. This principle ensures a consistent and thorough evaluation of skin tone, texture, lesions, temperature, or edema. Comparing both sides helps identify unilateral conditions and provides a clearer clinical picture, which is essential for accurate documentation and decision-making. This approach is fundamental in all physical assessments.

Why Other Options Are Wrong:

Use layman’s terms when reporting or documenting.

This is incorrect because healthcare professionals are expected to use accurate medical terminology in documentation to maintain clarity and standardization across providers. While layman’s terms may be used when speaking with patients, documentation should reflect professional language.

Inspect specific lesions before performing a generalized examination of the skin.

This is not the recommended sequence. Nurses should start with a general overview of the skin before focusing on specific lesions. A broad view helps provide context and identify patterns that may not be evident if the focus is limited early in the assessment.

Palpate the temperature of the skin with the fingertips.

This is an incorrect technique. The dorsum (back) of the hand, not the fingertips, is more sensitive to temperature and is the correct method for palpating skin temperature. Using fingertips may not provide an accurate thermal assessment.

Correct Answer:

Bright red blood in urine

Explanation:

Bright red blood in the urine following a cystoscopy may indicate active bleeding and should be reported immediately. While some mild hematuria (pink-tinged urine) is expected, bright red bleeding suggests a complication such as trauma or vessel injury during the procedure. This finding requires prompt evaluation by the provider to rule out serious issues and initiate appropriate treatment. It goes beyond expected post-procedure symptoms.

Why Other Options Are Wrong:

Urinary frequency

This is a common and expected side effect after cystoscopy due to bladder irritation. It typically resolves without intervention and does not signal a serious complication.

Pink-tinged urine

Mild hematuria is normal post-procedure and results from minor mucosal irritation. It usually subsides within a day or two and doesn’t require reporting unless it worsens.

Burning on urination

Dysuria can occur after cystoscopy as the urethra may be irritated. This symptom should be monitored, but it is not necessarily a complication unless accompanied by signs of infection or worsening discomfort.

Correct Answer:

“Monitor for tendon pain.”

Explanation:

Ciprofloxacin, a fluoroquinolone antibiotic, carries a black box warning for tendonitis and tendon rupture, particularly in older adults and those on corticosteroids. Patients should be instructed to report any new tendon pain, swelling, or inflammation, especially in the Achilles tendon. Early recognition and discontinuation of the drug can prevent further injury. Monitoring for musculoskeletal symptoms is a vital part of ciprofloxacin safety education.

Why Other Options Are Wrong:

“Take this medication with an antacid.”

This is incorrect because antacids containing magnesium or aluminum can interfere with ciprofloxacin absorption. Patients should be instructed to separate ciprofloxacin from antacids by several hours.

“Limit fluid intake while on this medication.”

Fluids should not be restricted while taking ciprofloxacin. In fact, maintaining adequate hydration is encouraged to prevent crystalluria and support renal function.

“Expect urine to turn dark orange.”

This is an expected side effect of phenazopyridine (Pyridium), not ciprofloxacin. Ciprofloxacin does not typically discolor urine, so this would be misleading.

Correct Answer:

The nurse separates the patient’s labia with the dominant hand.

Explanation:

During urinary catheterization, the non-dominant hand is used to separate the labia and maintain exposure of the urethral meatus. This hand is considered contaminated once it touches the patient and must remain in place. The dominant hand is used for the sterile procedure, including insertion of the catheter. Using the dominant hand to separate the labia compromises sterile technique and increases the risk of introducing infection. This is a key point where the charge nurse must intervene to maintain aseptic technique.

Why Other Options Are Wrong:

The nurse provides perineal care prior to inserting the urinary catheter.

This is correct practice. Cleaning the perineal area before catheter insertion helps minimize the risk of introducing bacteria into the urinary tract, reducing the chance of catheter-associated infections.

The nurse applies the sterile drape prior to inserting the urinary catheter.

This is standard and expected practice. Draping the area with sterile material helps establish a sterile field and maintain aseptic technique throughout the procedure.

The nurse coats the indwelling urinary catheter tip with lubricant.

Lubricating the catheter tip is essential to ease insertion and reduce patient discomfort or injury. This is a necessary and proper step in the procedure.

Correct Answer:

Electroencephalography (EEG)

Explanation:

An EEG (electroencephalogram) is the most appropriate diagnostic test for evaluating seizure disorders. It measures electrical activity in the brain and can identify abnormal patterns suggestive of epilepsy or other seizure conditions. The EEG helps determine the type and origin of seizures, aiding in diagnosis and treatment planning. It is noninvasive, commonly used, and essential for neurologic assessment in suspected seizure disorders.

Why Other Options Are Wrong:

Cerebral angiography

This imaging technique visualizes blood vessels in the brain and is more appropriate for detecting aneurysms or vascular malformations. It is not typically used to diagnose seizures.

Electromyography (EMG)

EMG assesses muscle and nerve function and is useful for conditions like neuropathy or myopathy. It does not evaluate brain activity and is unrelated to seizure assessment.

Lumbar puncture

A lumbar puncture may be used if infection (like meningitis) is suspected, but it is not the primary test for seizure disorders. It helps rule out CNS infections rather than identify seizure activity.

Correct Answer:

Lateral recumbent with chin resting on flexed knees

Explanation:

The lateral recumbent position with the patient’s back arched and chin resting on flexed knees allows maximum separation of the vertebrae. This positioning facilitates access to the subarachnoid space for the lumbar puncture. It also helps the patient remain still during the procedure, reducing the risk of needle misplacement. Correct positioning is essential to ensure safety and obtain accurate cerebrospinal fluid (CSF) samples.

Why Other Options Are Wrong:

Prone with the head turned to the right

The prone position does not adequately separate the vertebrae and is not standard for lumbar puncture. It also makes needle placement more difficult and less controlled.

Supine with the knees raised toward the chest

This position does not offer the same degree of spinal flexion as the lateral recumbent position. It is not ideal for accessing the lumbar subarachnoid space.

Prone with right leg flexed

Again, the prone position is incorrect for this procedure, and flexing just one leg does not aid spinal access. This posture may actually increase patient discomfort without benefit.