NUR 101 Exam 3
A. "I must protect my skin and eyes from
natural sunlight for 12 hours after taking
this medication."
B. "I will need to wear wraparound ultravi-
A client with atopic dermatitis is pre- olet-protective sunglasses both indoors
scribed medication for photochemother- and outdoors, from the moment I take the
apy. After administering medication for medication until nightfall on the treatment
photochemotherapy, the nurse deter- day."
mines that the client understands the in- C. "I will need to wear protective-wear
structions based on which client state- wraparound ultraviolet-protective sun-
ments? Select all that apply. glasses after dark if I am under fluores-
A. "I must protect my skin and eyes from cent lighting."
natural sunlight for 12 hours after taking E. "I will need to wear broad-spectrum
this medication." sunscreen if I am outside."
B. "I will need to wear wraparound ultravi-
olet-protective sunglasses both indoors Explanation: Clients must avoid sun ex-
and outdoors, from the moment I take posure even behind window glass for 12
the medication until nightfall on the treat- hours after ingesting medication for pho-
ment day." tochemotherapy such as methoxsalen.
C. "I will need to wear protective-wear Clients must protect their skin and eyes
wraparound ultraviolet-protective sun- from natural sunlight for 12 hours af-
glasses after dark if I am under fluores- ter taking the tablets. During treatment,
cent lighting." clients must wear wraparound ultravi-
D. "As long as I am inside behind a win- olet-protective sunglasses both indoors
dow glass I will not need to wear my and outdoors from the moment they take
protective glasses." the tablets until nightfall on treatment
E. "I will need to wear broad-spectrum day. After dark, the glasses must still be
sunscreen if I am outside." worn under fluorescent lighting, but are
not necessary outside or with incandes-
cent lamps. Clients should wear covering
clothing and apply broad-spectrum sun-
screens if outdoors.
B. ring or donut
The nurse is caring for a wheel-
chair-bound client. Which piece of equip- Explanation: Rings or donuts are not to
ment impedes circulation to the area it is be used because they restrict circula-
meant to protect? tion. An air-fluidized bed contains beads
A. air-fluidized bed that move under an airflow to support
the client, thus reducing shearing force
, NUR 101 Exam 3
and friction. Gel pads redistribute with
B. ring or donut
the client's weight. The water bed also
C. gel flotation pad
distributes pressure over the entire sur-
D. water bed
face.
B. Cover the protruding internal organs
with sterile gauze moistened with sterile
saline solution.
The nurse is caring for a client with
a postoperative wound evisceration.
Explanation: The nurse should first cov-
Which action should the nurse perform
er the wound with moistened gauze to
first?
prevent the organs from drying. Both
A. Explain to the client what is happening
the gauze and the saline solution must
and provide support.
be sterile to reduce the risk of infec-
B. Cover the protruding internal organs
tion. The nurse should provide support
with sterile gauze moistened with sterile
that will reduce the client's anxiety, but
saline solution.
covering the wound is the top priority.
C. Push the protruding organs back into
The organs should not be pushed back
the abdominal cavity.
into the abdomen because doing so may
D. Ask the client to drink as much fluid as
tear or damage them. Evisceration re-
possible.
quires emergency surgery; therefore, the
nurse should place the client on noth-
ing-by-mouth status immediately.
While assessing a client, a nurse notes
a stage I pressure ulcer on the client's
left hip. How should the nurse report this
finding?
A. Document the size, extent, and loca-
A. Document the size, extent, and loca-
tion of the wound in the client's medical
tion of the wound in the client's medical
record.
record.
B. Inform the client's family of the pres-
sure ulcer.
C. Notify a physician immediately.
D. Report the finding to a nurse-manager
immediately.
C. maintaining the client's fluid, elec-
When assisting with developing a plan
trolyte, and acid-base balance.
of care for a client recovering from a
serious thermal burn, the nurse knows
Explanation: The most important imme-
, NUR 101 Exam 3
diate goal of therapy for a client with a
that the most important immediate goal
serious thermal burn is to maintain flu-
of therapy is:
id, electrolyte, and acid-base balance to
A. planning for the client's rehabilitation
avoid potentially life- threatening com-
and discharge.
plications, such as shock, disseminated
B. providing emotional support to the
intravascular coagulation (DIC), respira-
client and family.
tory failure, cardiac failure, and acute
C. maintaining the client's fluid, elec-
tubular necrosis. The other options are
trolyte, and acid-base balance.
important aspects of care but don't take
D. preserving full range of motion in all
precedence over maintaining the client's
affected joints.
fluid, electrolyte, and acid-base balance.
A child was found unconscious at home B. Carbon monoxide poisoning
and brought to the emergency depart-
ment by the fire and rescue unit. While Explanation: Cherry-red skin changes
collecting data, the nurse observes cher- are seen when a child has been ex-
ry-red mucous membranes, nail beds, posed to high levels of carbon monoxide.
and skin. Which cause is the most likely Nausea and vomiting and pale skin are
explanation for the child's condition? symptoms of aspirin ingestion. A hydro-
A. Aspirin ingestion carbon or petroleum ingestion usually re-
B. Carbon monoxide poisoning sults in respiratory symptoms and tachy-
C. Hydrocarbon ingestion cardia. Spider-bite reactions are usually
D. Spider bite localized to the area of the bite.
C. Wound care nurse
A client transferred to a long-term care
facility has a stage II pressure ulcer on Explanation: The wound care nurse
her coccyx. Who should the nurse con- should be consulted for a treatment plan
sult about the care of this client? for this client. The charge nurse and
A. Charge nurse physician should be informed, but the
B. Physician wound care nurse will be the resource
C. Wound care nurse person to institute a wound care protocol.
D. Risk management Risk management should be informed if
pressure ulcers are a continual problem.
The nurse is gathering data from a client C. purulent drainage on a soiled wound
with an abdominal incision and suspects dressing
there is a potential for delayed wound
healing. Which observation most likely Explanation: Purulent drainage contains
supports this finding? white blood cells, which fight infection.
A. sutures dry and intact The sutures from a wound that is draining
, NUR 101 Exam 3
B. wound edges in close approximation purulent secretions would pull away with
C. purulent drainage on a soiled wound an infection. Wound edges can't approxi-
dressing mate in an infected wound. Sanguineous
D. sanguineous drainage in a wound-col- drainage indicates bleeding, not infec-
lection drainage bag tion.
The nurse is collecting data from several
clients at the clinic. Which client does the C. 62-year-old client that had a mild case
nurse determine is most likely receive of shingles 4 years previously
the Zostavax vaccine for the prevention
of shingles? Explanation: The Centers for Disease
A. 24-year old client that will be traveling Control and Prevention (CDC) recom-
out of the country mends that anyone 60 years of age or
B. 6-month-old infant having surgery to older receive the shingles vaccine, even
repair a cleft lip if they have had a previous case of shin-
C. 62-year-old client that had a mild case gles to prevent reoccurrence of the virus.
of shingles 4 years previously The other clients are not at greater risk
D. 38-year-old pregnant client that has for the development of shingles.
gestational diabetes
The nurse is preparing to perform wound
B. wash hands thoroughly
care for a client. What action should
the nurse prioritize before changing the
Explanation: The first thing the nurse
dressing?
must do is wash hands. Putting on
A. put on gloves
gloves, removing the dressing, and ob-
B. wash hands thoroughly
serving the drainage are all parts of the
C. slowly remove the soiled dressing
dressing change procedure that come
D. observe the dressing for the amount,
after hand washing.
type, and odor of drainage
The nurse is reinforcing education to par-
ents of an infant about burn prevention. C. Before putting the infant in the tub, test
Which instructions should be reinforced the water with a hand.
regarding burns from tap water?
A. Set the water-heater temperature at Explanation: Instruct the parents to fill
130° F (54.4° C) or less. the tub with water first, then test all of
B. Run the hot water first, then adjust the the water in the tub with a hand for hot
temperature with cold water. spots. The cold water should be run first
C. Before putting the infant in the tub, test and then adjusted with hot water. Water
the water with a hand. heaters should be set at 120° F (48.9°
D. Supervise an infant in the bathroom,
A. "I must protect my skin and eyes from
natural sunlight for 12 hours after taking
this medication."
B. "I will need to wear wraparound ultravi-
A client with atopic dermatitis is pre- olet-protective sunglasses both indoors
scribed medication for photochemother- and outdoors, from the moment I take the
apy. After administering medication for medication until nightfall on the treatment
photochemotherapy, the nurse deter- day."
mines that the client understands the in- C. "I will need to wear protective-wear
structions based on which client state- wraparound ultraviolet-protective sun-
ments? Select all that apply. glasses after dark if I am under fluores-
A. "I must protect my skin and eyes from cent lighting."
natural sunlight for 12 hours after taking E. "I will need to wear broad-spectrum
this medication." sunscreen if I am outside."
B. "I will need to wear wraparound ultravi-
olet-protective sunglasses both indoors Explanation: Clients must avoid sun ex-
and outdoors, from the moment I take posure even behind window glass for 12
the medication until nightfall on the treat- hours after ingesting medication for pho-
ment day." tochemotherapy such as methoxsalen.
C. "I will need to wear protective-wear Clients must protect their skin and eyes
wraparound ultraviolet-protective sun- from natural sunlight for 12 hours af-
glasses after dark if I am under fluores- ter taking the tablets. During treatment,
cent lighting." clients must wear wraparound ultravi-
D. "As long as I am inside behind a win- olet-protective sunglasses both indoors
dow glass I will not need to wear my and outdoors from the moment they take
protective glasses." the tablets until nightfall on treatment
E. "I will need to wear broad-spectrum day. After dark, the glasses must still be
sunscreen if I am outside." worn under fluorescent lighting, but are
not necessary outside or with incandes-
cent lamps. Clients should wear covering
clothing and apply broad-spectrum sun-
screens if outdoors.
B. ring or donut
The nurse is caring for a wheel-
chair-bound client. Which piece of equip- Explanation: Rings or donuts are not to
ment impedes circulation to the area it is be used because they restrict circula-
meant to protect? tion. An air-fluidized bed contains beads
A. air-fluidized bed that move under an airflow to support
the client, thus reducing shearing force
, NUR 101 Exam 3
and friction. Gel pads redistribute with
B. ring or donut
the client's weight. The water bed also
C. gel flotation pad
distributes pressure over the entire sur-
D. water bed
face.
B. Cover the protruding internal organs
with sterile gauze moistened with sterile
saline solution.
The nurse is caring for a client with
a postoperative wound evisceration.
Explanation: The nurse should first cov-
Which action should the nurse perform
er the wound with moistened gauze to
first?
prevent the organs from drying. Both
A. Explain to the client what is happening
the gauze and the saline solution must
and provide support.
be sterile to reduce the risk of infec-
B. Cover the protruding internal organs
tion. The nurse should provide support
with sterile gauze moistened with sterile
that will reduce the client's anxiety, but
saline solution.
covering the wound is the top priority.
C. Push the protruding organs back into
The organs should not be pushed back
the abdominal cavity.
into the abdomen because doing so may
D. Ask the client to drink as much fluid as
tear or damage them. Evisceration re-
possible.
quires emergency surgery; therefore, the
nurse should place the client on noth-
ing-by-mouth status immediately.
While assessing a client, a nurse notes
a stage I pressure ulcer on the client's
left hip. How should the nurse report this
finding?
A. Document the size, extent, and loca-
A. Document the size, extent, and loca-
tion of the wound in the client's medical
tion of the wound in the client's medical
record.
record.
B. Inform the client's family of the pres-
sure ulcer.
C. Notify a physician immediately.
D. Report the finding to a nurse-manager
immediately.
C. maintaining the client's fluid, elec-
When assisting with developing a plan
trolyte, and acid-base balance.
of care for a client recovering from a
serious thermal burn, the nurse knows
Explanation: The most important imme-
, NUR 101 Exam 3
diate goal of therapy for a client with a
that the most important immediate goal
serious thermal burn is to maintain flu-
of therapy is:
id, electrolyte, and acid-base balance to
A. planning for the client's rehabilitation
avoid potentially life- threatening com-
and discharge.
plications, such as shock, disseminated
B. providing emotional support to the
intravascular coagulation (DIC), respira-
client and family.
tory failure, cardiac failure, and acute
C. maintaining the client's fluid, elec-
tubular necrosis. The other options are
trolyte, and acid-base balance.
important aspects of care but don't take
D. preserving full range of motion in all
precedence over maintaining the client's
affected joints.
fluid, electrolyte, and acid-base balance.
A child was found unconscious at home B. Carbon monoxide poisoning
and brought to the emergency depart-
ment by the fire and rescue unit. While Explanation: Cherry-red skin changes
collecting data, the nurse observes cher- are seen when a child has been ex-
ry-red mucous membranes, nail beds, posed to high levels of carbon monoxide.
and skin. Which cause is the most likely Nausea and vomiting and pale skin are
explanation for the child's condition? symptoms of aspirin ingestion. A hydro-
A. Aspirin ingestion carbon or petroleum ingestion usually re-
B. Carbon monoxide poisoning sults in respiratory symptoms and tachy-
C. Hydrocarbon ingestion cardia. Spider-bite reactions are usually
D. Spider bite localized to the area of the bite.
C. Wound care nurse
A client transferred to a long-term care
facility has a stage II pressure ulcer on Explanation: The wound care nurse
her coccyx. Who should the nurse con- should be consulted for a treatment plan
sult about the care of this client? for this client. The charge nurse and
A. Charge nurse physician should be informed, but the
B. Physician wound care nurse will be the resource
C. Wound care nurse person to institute a wound care protocol.
D. Risk management Risk management should be informed if
pressure ulcers are a continual problem.
The nurse is gathering data from a client C. purulent drainage on a soiled wound
with an abdominal incision and suspects dressing
there is a potential for delayed wound
healing. Which observation most likely Explanation: Purulent drainage contains
supports this finding? white blood cells, which fight infection.
A. sutures dry and intact The sutures from a wound that is draining
, NUR 101 Exam 3
B. wound edges in close approximation purulent secretions would pull away with
C. purulent drainage on a soiled wound an infection. Wound edges can't approxi-
dressing mate in an infected wound. Sanguineous
D. sanguineous drainage in a wound-col- drainage indicates bleeding, not infec-
lection drainage bag tion.
The nurse is collecting data from several
clients at the clinic. Which client does the C. 62-year-old client that had a mild case
nurse determine is most likely receive of shingles 4 years previously
the Zostavax vaccine for the prevention
of shingles? Explanation: The Centers for Disease
A. 24-year old client that will be traveling Control and Prevention (CDC) recom-
out of the country mends that anyone 60 years of age or
B. 6-month-old infant having surgery to older receive the shingles vaccine, even
repair a cleft lip if they have had a previous case of shin-
C. 62-year-old client that had a mild case gles to prevent reoccurrence of the virus.
of shingles 4 years previously The other clients are not at greater risk
D. 38-year-old pregnant client that has for the development of shingles.
gestational diabetes
The nurse is preparing to perform wound
B. wash hands thoroughly
care for a client. What action should
the nurse prioritize before changing the
Explanation: The first thing the nurse
dressing?
must do is wash hands. Putting on
A. put on gloves
gloves, removing the dressing, and ob-
B. wash hands thoroughly
serving the drainage are all parts of the
C. slowly remove the soiled dressing
dressing change procedure that come
D. observe the dressing for the amount,
after hand washing.
type, and odor of drainage
The nurse is reinforcing education to par-
ents of an infant about burn prevention. C. Before putting the infant in the tub, test
Which instructions should be reinforced the water with a hand.
regarding burns from tap water?
A. Set the water-heater temperature at Explanation: Instruct the parents to fill
130° F (54.4° C) or less. the tub with water first, then test all of
B. Run the hot water first, then adjust the the water in the tub with a hand for hot
temperature with cold water. spots. The cold water should be run first
C. Before putting the infant in the tub, test and then adjusted with hot water. Water
the water with a hand. heaters should be set at 120° F (48.9°
D. Supervise an infant in the bathroom,
