NSG 122 FUNDAMENTAL UPDATED EXAM SCRIPT
QUESTIONS AND SOLUTIONS RATED A+
✔✔Pressure Ulcer Stage 3 - ✔✔A stage 3 pressure injury presents with full-thickness
tissue loss. Subcutaneous fat may be visible and epibole (rolled wound edges) may
occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar that may be
present do not obscure the depth of tissue loss. Ulcers
✔✔Pressure Ulcer Stage 4 - ✔✔Stage 4 injuries involve full-thickness tissue loss with
exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or
eschar may be present on some part of the wound bed; epibole, undermining, and/or
tunneling often occur
✔✔Wound Infection - ✔✔Symptoms of infection include purulent drainage; increased
drainage, pain, redness, and swelling in and around the wound; increased body
temperature; and increased white blood cell count. Additional signs and symptoms
include delayed healing and discoloration of granulation tissue in the wound
✔✔Braden Scale - ✔✔Braden Scale: mental status, continence, mobility, activity, and
nutrition
Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to
14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk
✔✔Heat Application - ✔✔The application of heat accelerates the inflammatory response
to promote healing.
The application of local heat dilates peripheral blood vessels, increases tissue
metabolism, reduces blood viscosity and increases capillary permeability, reduces
muscle tension, and helps relieve pain. Vasodilation increases local blood flow. In turn,
the supply of oxygen and nutrients to the area is increased, and venous congestion is
decreased
Careful on large parts of the body
✔✔Dysnpea Positioning - ✔✔High Fowler's Position because accessory muscles can
easily be used to promote respirations
✔✔Partial Rebreather Mask - ✔✔Low Flow 8-11L/min, set flow rate so the mask
remains two thirds full during inspiration, keep reservoir bag free of twists or kinks
✔✔Cyanosis - ✔✔Cyanosis (bluish discoloration) of these areas indicates decreased
blood flow or poor blood oxygenation
✔✔Fish Oil - ✔✔Of all the natural products, fish oil and glucosamine, chondroitin, or a
combination supplement were the products most commonly used by adults in 2012.
Beneficial to many aspects of health
, ✔✔Ventrogluteal - ✔✔The ventrogluteal site is recommended for general IM injections
in adults
✔✔Adult Ear Drop Administration - ✔✔up and back
✔✔Clear Liquid Diet - ✔✔only clear liquids
✔✔GT Feeding Residual - ✔✔Check gastric residual (feeding remaining in the
stomach) before each feeding or every 4 to 6 hours during a continuous feeding
(according to institution policy). High gastric residual volumes (200 to 250 mL or
greater) can be associated with high risk for aspiration and aspiration-related
pneumonia
✔✔24 Hour Urine Specimen - ✔✔Collection of ALL urine voided during a 24 hour
period.
Initiate a collection at a specific time (which is recorded) by asking the patient to empty
the bladder. Discard this urine and then collect all urine voided for the next 24 hours. At
the end of the 24 hours, ask the patient to void. Add this urine to the previously
collected urine, and then send the entire specimen to the laboratory.
✔✔Catheter Insertion Steps Female - ✔✔Hand Hygiene
Assist patient in to dorsal recumbent position with knees flexed
Open cath tray with sterile technique
With thumb and finger of nondominant hand, spread the labia and identify the meatus.
Using the dominant hand, clean the labial fold from top to bottom.
With the dominant hand, hold a lubricated catheter 2 to 3 inches from the tip and insert
slowly into the urethra.
Advance the catheter another 2 to 3 inches after the initial return of urine.
Inflate catheter balloon
Secure to patient's leg
✔✔Relocation Stress Syndrome - ✔✔Relocation stress syndrome is a nursing diagnosis
characterized by symptoms such as anxiety, confusion, hopelessness, and loneliness. It
usually occurs in older adults shortly after moving from a private residence to a nursing
home or assisted-living facility.
✔✔Pain Symptoms Older Adults - ✔✔Chronic Pain:
Assessing pain in the older adult population can be challenging. Adults over the age of
65 experience pain more frequently than do younger adults.
✔✔Anticipatory Loss - ✔✔Anticipatory loss occurs when a person displays loss and
grief behaviors for a loss that has yet to take place. Anticipatory loss is often seen in the
families of patients with serious and life-threatening illnesses and may lessen the effect
of the actual loss of the family member.
QUESTIONS AND SOLUTIONS RATED A+
✔✔Pressure Ulcer Stage 3 - ✔✔A stage 3 pressure injury presents with full-thickness
tissue loss. Subcutaneous fat may be visible and epibole (rolled wound edges) may
occur, but bone, tendon, or muscle is not exposed. Slough and/or eschar that may be
present do not obscure the depth of tissue loss. Ulcers
✔✔Pressure Ulcer Stage 4 - ✔✔Stage 4 injuries involve full-thickness tissue loss with
exposed or palpable bone, cartilage, ligament, tendon, fascia, or muscle. Slough or
eschar may be present on some part of the wound bed; epibole, undermining, and/or
tunneling often occur
✔✔Wound Infection - ✔✔Symptoms of infection include purulent drainage; increased
drainage, pain, redness, and swelling in and around the wound; increased body
temperature; and increased white blood cell count. Additional signs and symptoms
include delayed healing and discoloration of granulation tissue in the wound
✔✔Braden Scale - ✔✔Braden Scale: mental status, continence, mobility, activity, and
nutrition
Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to
14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk
✔✔Heat Application - ✔✔The application of heat accelerates the inflammatory response
to promote healing.
The application of local heat dilates peripheral blood vessels, increases tissue
metabolism, reduces blood viscosity and increases capillary permeability, reduces
muscle tension, and helps relieve pain. Vasodilation increases local blood flow. In turn,
the supply of oxygen and nutrients to the area is increased, and venous congestion is
decreased
Careful on large parts of the body
✔✔Dysnpea Positioning - ✔✔High Fowler's Position because accessory muscles can
easily be used to promote respirations
✔✔Partial Rebreather Mask - ✔✔Low Flow 8-11L/min, set flow rate so the mask
remains two thirds full during inspiration, keep reservoir bag free of twists or kinks
✔✔Cyanosis - ✔✔Cyanosis (bluish discoloration) of these areas indicates decreased
blood flow or poor blood oxygenation
✔✔Fish Oil - ✔✔Of all the natural products, fish oil and glucosamine, chondroitin, or a
combination supplement were the products most commonly used by adults in 2012.
Beneficial to many aspects of health
, ✔✔Ventrogluteal - ✔✔The ventrogluteal site is recommended for general IM injections
in adults
✔✔Adult Ear Drop Administration - ✔✔up and back
✔✔Clear Liquid Diet - ✔✔only clear liquids
✔✔GT Feeding Residual - ✔✔Check gastric residual (feeding remaining in the
stomach) before each feeding or every 4 to 6 hours during a continuous feeding
(according to institution policy). High gastric residual volumes (200 to 250 mL or
greater) can be associated with high risk for aspiration and aspiration-related
pneumonia
✔✔24 Hour Urine Specimen - ✔✔Collection of ALL urine voided during a 24 hour
period.
Initiate a collection at a specific time (which is recorded) by asking the patient to empty
the bladder. Discard this urine and then collect all urine voided for the next 24 hours. At
the end of the 24 hours, ask the patient to void. Add this urine to the previously
collected urine, and then send the entire specimen to the laboratory.
✔✔Catheter Insertion Steps Female - ✔✔Hand Hygiene
Assist patient in to dorsal recumbent position with knees flexed
Open cath tray with sterile technique
With thumb and finger of nondominant hand, spread the labia and identify the meatus.
Using the dominant hand, clean the labial fold from top to bottom.
With the dominant hand, hold a lubricated catheter 2 to 3 inches from the tip and insert
slowly into the urethra.
Advance the catheter another 2 to 3 inches after the initial return of urine.
Inflate catheter balloon
Secure to patient's leg
✔✔Relocation Stress Syndrome - ✔✔Relocation stress syndrome is a nursing diagnosis
characterized by symptoms such as anxiety, confusion, hopelessness, and loneliness. It
usually occurs in older adults shortly after moving from a private residence to a nursing
home or assisted-living facility.
✔✔Pain Symptoms Older Adults - ✔✔Chronic Pain:
Assessing pain in the older adult population can be challenging. Adults over the age of
65 experience pain more frequently than do younger adults.
✔✔Anticipatory Loss - ✔✔Anticipatory loss occurs when a person displays loss and
grief behaviors for a loss that has yet to take place. Anticipatory loss is often seen in the
families of patients with serious and life-threatening illnesses and may lessen the effect
of the actual loss of the family member.
