NSG 521 UNIT 5 EXAM
A nurse is assessing the skin of an immobile patient. The nurse notes a
small, intact blister on the patient's heel. What is the most appropriate
classification for this finding?
Stage 1 pressure injury
Stage 2 pressure injury
Stage 3 pressure injury
Deep tissue injury - ANSWERS-Stage 2 pressure injury
Rationale: A blister is characteristic of a stage 2 pressure injury, which
involves partial-thickness skin loss. Stage 1 pressure injuries involve
non-blanchable redness without blistering.
A client is experiencing pain following surgery and asks the nurse for
pain medication. The nurse administers the prescribed analgesic, but
the client continues to report severe pain 30 minutes later. What is the
nurse's next best action?
Reassess the pain and perform a focused physical examination.
Notify the healthcare provider that the current pain medication is
ineffective.
Administer an additional dose of the prescribed pain medication.
Suggest non-pharmacological methods of pain relief such as heat or
ice. - ANSWERS-Reassess the pain and perform a focused physical
examination.
,Rationale: The nurse's first action should be to reassess the patient's
pain and perform a focused assessment before escalating the issue to
the provider or administering additional medications.
A nurse is caring for a client with chronic neuropathic pain. Which of
the following medications is most appropriate for managing this type
of pain?
Acetaminophen
Ibuprofen
Gabapentin
Aspirin - ANSWERS-Gabapentin
Rationale: Neuropathic pain results from nerve damage and is best
managed with anticonvulsants like gabapentin, which help stabilize
nerve activity. Acetaminophen and ibuprofen are better suited for
nociceptive pain, while aspirin is primarily used for its anti-
inflammatory properties.
While performing a general survey, the nurse notices a patient with
poor hygiene and disheveled clothing. What might this indicate?
The patient has a history of chronic illness.
The patient is experiencing an acute infection.
The patient may be experiencing neglect or mental health issues.
The patient is likely recovering from a surgical procedure. -
ANSWERS-The patient may be experiencing neglect or mental health
issues.
Rationale: Poor hygiene and disheveled appearance may be indicators
of neglect, mental health disorders, or inability to care for oneself,
, potentially due to cognitive or emotional impairments. It may also
indicate social or financial difficulties.
The nurse is teaching an assistive personnel (AP) about assessing a
patient's temperature. Which statement by the AP requires further
teaching?
"I will take an oral temperature for a patient who has nasal
congestion."
"I will wait 30 minutes after a patient drinks a hot beverage before
taking an oral temperature."
"I can take an axillary temperature for a patient with a wound on the
chest."
"I will avoid taking a rectal temperature in a patient with diarrhea." -
ANSWERS-"I will take an oral temperature for a patient who has
nasal congestion."
Rationale: Nasal congestion can affect the patient's ability to breathe
through the nose, making it difficult to take an accurate oral
temperature. Other methods such as tympanic or axillary are
preferable in this case.
A patient reports 7/10 pain after surgery and is visibly restless. What
is the nurse's priority action?
Document the patient's pain and continue monitoring.
Administer prescribed pain medication.
Encourage the patient to try relaxation techniques.
A nurse is assessing the skin of an immobile patient. The nurse notes a
small, intact blister on the patient's heel. What is the most appropriate
classification for this finding?
Stage 1 pressure injury
Stage 2 pressure injury
Stage 3 pressure injury
Deep tissue injury - ANSWERS-Stage 2 pressure injury
Rationale: A blister is characteristic of a stage 2 pressure injury, which
involves partial-thickness skin loss. Stage 1 pressure injuries involve
non-blanchable redness without blistering.
A client is experiencing pain following surgery and asks the nurse for
pain medication. The nurse administers the prescribed analgesic, but
the client continues to report severe pain 30 minutes later. What is the
nurse's next best action?
Reassess the pain and perform a focused physical examination.
Notify the healthcare provider that the current pain medication is
ineffective.
Administer an additional dose of the prescribed pain medication.
Suggest non-pharmacological methods of pain relief such as heat or
ice. - ANSWERS-Reassess the pain and perform a focused physical
examination.
,Rationale: The nurse's first action should be to reassess the patient's
pain and perform a focused assessment before escalating the issue to
the provider or administering additional medications.
A nurse is caring for a client with chronic neuropathic pain. Which of
the following medications is most appropriate for managing this type
of pain?
Acetaminophen
Ibuprofen
Gabapentin
Aspirin - ANSWERS-Gabapentin
Rationale: Neuropathic pain results from nerve damage and is best
managed with anticonvulsants like gabapentin, which help stabilize
nerve activity. Acetaminophen and ibuprofen are better suited for
nociceptive pain, while aspirin is primarily used for its anti-
inflammatory properties.
While performing a general survey, the nurse notices a patient with
poor hygiene and disheveled clothing. What might this indicate?
The patient has a history of chronic illness.
The patient is experiencing an acute infection.
The patient may be experiencing neglect or mental health issues.
The patient is likely recovering from a surgical procedure. -
ANSWERS-The patient may be experiencing neglect or mental health
issues.
Rationale: Poor hygiene and disheveled appearance may be indicators
of neglect, mental health disorders, or inability to care for oneself,
, potentially due to cognitive or emotional impairments. It may also
indicate social or financial difficulties.
The nurse is teaching an assistive personnel (AP) about assessing a
patient's temperature. Which statement by the AP requires further
teaching?
"I will take an oral temperature for a patient who has nasal
congestion."
"I will wait 30 minutes after a patient drinks a hot beverage before
taking an oral temperature."
"I can take an axillary temperature for a patient with a wound on the
chest."
"I will avoid taking a rectal temperature in a patient with diarrhea." -
ANSWERS-"I will take an oral temperature for a patient who has
nasal congestion."
Rationale: Nasal congestion can affect the patient's ability to breathe
through the nose, making it difficult to take an accurate oral
temperature. Other methods such as tympanic or axillary are
preferable in this case.
A patient reports 7/10 pain after surgery and is visibly restless. What
is the nurse's priority action?
Document the patient's pain and continue monitoring.
Administer prescribed pain medication.
Encourage the patient to try relaxation techniques.
