NUR 355 Exam 1: Connection Checks and Review Questions
With Complete Solutions
A 5-year-old patient will be returning home after
surgery for a right inguinal hernia repair. Which of
the following is an important teaching need before the child and
family leave the hospital?
A. The child should be given pain medicine
every 4 hours for the first 24 hours.
B. There will be no dressing for the family to check because of
the laparoscopic surgery.
C. Teach the family how to use the facial pain scale to ensure
that the child gets pain medication as needed.
D. Make sure the child is kept in bed for the first
12 hours to prevent bleeding from the operative site. Correct
Answers Answer: C
Rationale: You do not want to give the child pain medication if
they do not need it, so you must teach them how to use the facial
pain scale to indicate when the child needs pain medication.
There is a dressing over the puncture sites in laparoscopic
surgery. The child should be as ambulatory and mobile as is
tolerated to prevent venous stasis.
A 78-year-old patient fractured a hip 1 week ago and is now
being admitted to a rehabilitation facility for physical therapy
because of difficulty ambulating. During the admission skin
assessment, the nurse notesan area of non-blanchable erythema
on the sacrum.
What is the nursing priority at this time?
A. Order a redistributing mattress for her bed.
B. Consult the nutritionist for a complete nutritional assessment.
,C. Perform and document the admission skin and risk
assessments.
D. Apply a hydrocolloid dressing over the area to
protect it from further trauma. Correct Answers Answer: C
Rationale: Non-blanchable erythema is considered a stage I PU.
Any evidence of pressure on the body of the patient being
admitted to a healthcare facility must be
documented on the admission skin assessment or the institution
could be held responsible for causing it and may not get
reimbursed for treating it. The other three
answers are important and should be instituted, but the
admission skin and risk assessments must be completed at time
of admission.
A 78-year-old woman has had a history of an open stage IV
pressure ulcer for 6 months. What is the patient at high risk for
developing?
A. Hypergranulation tissue
B. Necrotic tissue
C. Osteomyelitis
D. Eschar Correct Answers Answer: C
Rationale: A clinical diagnosis of osteomyelitis is made based
on the presence of exposed bone.
A break in the skin that is caused by penetration
of a sharp object or high shearing forces that can
be superficial or deep is a:
A. Skin tear
B. Abrasion
C. Laceration
D. Pressure ulcer Correct Answers Answer: C
,A mother brings in her 8-year-old child because of a new rash of
annular patches, raised borders, and central clearing. What
should be done first?
A. Obtain a scraping of the rash for KOH microscopy.
B. Explain to the mother that this is probably tinea
corporis and an antifungal ointment will
successfully treat it.
C. Obtain a focused history to include medications, activities in
which the patient partakes, and any
history of skin disorders or fungal rashes.
D. Explain to the mother that the rash will subside on its own.
Correct Answers Answer: C
Rationale: The diagnosis of tinea infections can be made with a
focused history, physical exam, and potassium hydroxide
microscopy (KOH). Certainly, obtaining the skin scrapings for
KOH microscopy is important to confirm diagnosis but, as with
all healthcare visits, obtaining a history should be completed
first.
A nurse in the intensive care unit is evaluating a
critically ill patient who has a flat, erythematous
rash surrounded with small satellite lesions between her skin
folds, under her breasts, and in her groin. The nurse knows to
monitor this patient for clinical manifestations of which
disorder?
A. Necrotizing fasciitis
B. Systemic bacteremia
C. Pseudomonas infection
D. Systemic candidemia Correct Answers Answer: D
, Rationale: Complications of fungal infections, such as a
systemic candida infection, occur when they are not treated
promptly and are allowed to proliferate, especially in the
critically ill and immunocompromised patient.
A patient has been admitted to the critical unit with a serum
magnesium level of 0.9 mEq/L. The nurse closely monitors the
patient for which potential complication of this magnesium
level?
A. Agitation and restlessness
B. Hypotension and bradycardia
C. Deep, rapid respirations
D. Seizure and ventricular fibrillation Correct Answers
Answer: D
Rationale: Patients with low magnesium levels are at risk for
seizure and ventricular fibrillation. Agitation and restlessness are
seen with hypernatremia. Hypotension and bradycardia are
associated with high magnesium levels, and deep, rapid
respirations are observed with patients with hypochloremia.
A patient has been diagnosed with an intestinal
obstruction. The nurse inserts a nasogastric tube and attaches the
tube to low continuous suction. For which acid-base imbalance
is the patient at greatest risk?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis Correct Answers Answer: D
Rationale: The most common cause of metabolic alkalosis is
excessive acid loss from the GI tract, which can occur from
vomiting or prolonged NG suctioning.
With Complete Solutions
A 5-year-old patient will be returning home after
surgery for a right inguinal hernia repair. Which of
the following is an important teaching need before the child and
family leave the hospital?
A. The child should be given pain medicine
every 4 hours for the first 24 hours.
B. There will be no dressing for the family to check because of
the laparoscopic surgery.
C. Teach the family how to use the facial pain scale to ensure
that the child gets pain medication as needed.
D. Make sure the child is kept in bed for the first
12 hours to prevent bleeding from the operative site. Correct
Answers Answer: C
Rationale: You do not want to give the child pain medication if
they do not need it, so you must teach them how to use the facial
pain scale to indicate when the child needs pain medication.
There is a dressing over the puncture sites in laparoscopic
surgery. The child should be as ambulatory and mobile as is
tolerated to prevent venous stasis.
A 78-year-old patient fractured a hip 1 week ago and is now
being admitted to a rehabilitation facility for physical therapy
because of difficulty ambulating. During the admission skin
assessment, the nurse notesan area of non-blanchable erythema
on the sacrum.
What is the nursing priority at this time?
A. Order a redistributing mattress for her bed.
B. Consult the nutritionist for a complete nutritional assessment.
,C. Perform and document the admission skin and risk
assessments.
D. Apply a hydrocolloid dressing over the area to
protect it from further trauma. Correct Answers Answer: C
Rationale: Non-blanchable erythema is considered a stage I PU.
Any evidence of pressure on the body of the patient being
admitted to a healthcare facility must be
documented on the admission skin assessment or the institution
could be held responsible for causing it and may not get
reimbursed for treating it. The other three
answers are important and should be instituted, but the
admission skin and risk assessments must be completed at time
of admission.
A 78-year-old woman has had a history of an open stage IV
pressure ulcer for 6 months. What is the patient at high risk for
developing?
A. Hypergranulation tissue
B. Necrotic tissue
C. Osteomyelitis
D. Eschar Correct Answers Answer: C
Rationale: A clinical diagnosis of osteomyelitis is made based
on the presence of exposed bone.
A break in the skin that is caused by penetration
of a sharp object or high shearing forces that can
be superficial or deep is a:
A. Skin tear
B. Abrasion
C. Laceration
D. Pressure ulcer Correct Answers Answer: C
,A mother brings in her 8-year-old child because of a new rash of
annular patches, raised borders, and central clearing. What
should be done first?
A. Obtain a scraping of the rash for KOH microscopy.
B. Explain to the mother that this is probably tinea
corporis and an antifungal ointment will
successfully treat it.
C. Obtain a focused history to include medications, activities in
which the patient partakes, and any
history of skin disorders or fungal rashes.
D. Explain to the mother that the rash will subside on its own.
Correct Answers Answer: C
Rationale: The diagnosis of tinea infections can be made with a
focused history, physical exam, and potassium hydroxide
microscopy (KOH). Certainly, obtaining the skin scrapings for
KOH microscopy is important to confirm diagnosis but, as with
all healthcare visits, obtaining a history should be completed
first.
A nurse in the intensive care unit is evaluating a
critically ill patient who has a flat, erythematous
rash surrounded with small satellite lesions between her skin
folds, under her breasts, and in her groin. The nurse knows to
monitor this patient for clinical manifestations of which
disorder?
A. Necrotizing fasciitis
B. Systemic bacteremia
C. Pseudomonas infection
D. Systemic candidemia Correct Answers Answer: D
, Rationale: Complications of fungal infections, such as a
systemic candida infection, occur when they are not treated
promptly and are allowed to proliferate, especially in the
critically ill and immunocompromised patient.
A patient has been admitted to the critical unit with a serum
magnesium level of 0.9 mEq/L. The nurse closely monitors the
patient for which potential complication of this magnesium
level?
A. Agitation and restlessness
B. Hypotension and bradycardia
C. Deep, rapid respirations
D. Seizure and ventricular fibrillation Correct Answers
Answer: D
Rationale: Patients with low magnesium levels are at risk for
seizure and ventricular fibrillation. Agitation and restlessness are
seen with hypernatremia. Hypotension and bradycardia are
associated with high magnesium levels, and deep, rapid
respirations are observed with patients with hypochloremia.
A patient has been diagnosed with an intestinal
obstruction. The nurse inserts a nasogastric tube and attaches the
tube to low continuous suction. For which acid-base imbalance
is the patient at greatest risk?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis Correct Answers Answer: D
Rationale: The most common cause of metabolic alkalosis is
excessive acid loss from the GI tract, which can occur from
vomiting or prolonged NG suctioning.
