NR-224 Fundamentals – Skills - Set 5 - Part 1

Correct Answer: Half the plate fruits and vegetables

The plate model gives half the surface to fruits and vegetables, with vegetables the larger share. Grains and protein foods split the other half, at least half of the grains whole, with dairy alongside. Option b is incorrect because grains share the second half of the plate with protein foods and take only slightly the larger of those two portions. Giving them half crowds out produce. Option c is incorrect because protein foods occupy roughly a quarter of the plate. Doubling that portion displaces the vegetables and whole grains that carry the fiber, potassium and vitamins the guidance is built around. Option d is incorrect because dairy is not part of the plate itself. It appears as a cup set to the side, and low fat or fat free choices are the ones recommended.

Correct Answer: Decline, and limit each application to twenty minutes

Heat is applied for fifteen to twenty minutes and then removed, because longer application triggers reflex vasoconstriction and raises burn risk. This client cannot feel a burn developing, and lying on a heat source traps heat against the skin. Option a is incorrect because comfort is not a safe guide in a client whose sensation is impaired. Neuropathy blunts the warning that skin is being damaged, so the nurse controls temperature and duration instead. Option b is incorrect because two hours of continuous heat is past the point where vessels begin to constrict, and checking that late would find an injury rather than prevent one. Skin is inspected every five to ten minutes. Option d is incorrect because cold is the wrong therapy for a stiff joint and is itself hazardous in diabetic vascular disease. Refusing the request is right, but the substitution reduces flow to tissue that already has too little.

Correct Answer: "I will discard formula left hanging after eight hours."

Formula decanted into an open bag is limited to about eight hours, because handling introduces bacteria and formula at room temperature is an excellent growth medium. Contaminated formula causes diarrhea and, in vulnerable clients, sepsis. Option b is incorrect because topping off mixes fresh formula with formula that has been sitting and growing organisms. The bag is emptied and rinsed, or replaced, before new formula goes in. Option c is incorrect because a microwave heats unevenly and creates hot spots that can burn the gastric mucosa. Formula is brought to room temperature on the counter or by holding it briefly in warm water. Option d is incorrect because an opened container belongs in the refrigerator and is discarded within twenty-four hours. Left out overnight it becomes the same bacterial culture that causes tube feeding diarrhea and gastrointestinal infection.

Correct Answer: A calcium alginate rope packed loosely

Alginate absorbs many times its own weight, gels on contact with exudate and comes in rope form that fills a cavity. It suits a heavily draining wound and keeps the base moist while a secondary dressing holds it. Option a is incorrect because film has no absorbency whatever. Placed over a wound this wet it traps fluid against the surface, macerates the surrounding skin and lifts at the edges, and it cannot fill a cavity. Option b is incorrect because hydrogel donates moisture rather than taking it up, which is what a dry wound or one with adherent slough needs. Adding water to a wound already producing this much fluid would flood the periwound skin. Option d is incorrect because plain dry gauze dries onto a granulating base and pulls new tissue off when it is lifted. It would also need changing several times a day to keep up with this volume of drainage.

Correct Answer: Containing the effluent and protecting surrounding skin

Intestinal effluent carries digestive enzymes that strip periwound skin within hours, and the volume lost threatens fluid and electrolyte balance. A pouching system contains and measures the drainage while barrier products protect the skin. Option a is incorrect because a fistula tract cannot be closed by packing it, and forcing material into it raises pressure and worsens the leak. Closure is a surgical or spontaneous process managed over weeks, not at the bedside. Option b is incorrect because gauze soaks through, holds corrosive drainage against the skin and gives no measurement of output. Hourly changes also expose fragile skin to repeated adhesive trauma without solving the underlying containment problem. Option c is incorrect because bulking the stool and walking address constipation, a problem this client does not have. Many clients with a high output fistula need bowel rest and parenteral nutrition rather than more oral intake.

Correct Answer: The drain has lost its suction

A compression drain works only when the reservoir is squeezed flat and capped while still compressed. A bulb that has sprung back open with almost nothing in it means the vacuum was never established or has leaked away. Option a is incorrect because heavy drainage fills the bulb with fluid rather than air. The reservoir described holds only a few milliliters, so the expansion came from air entering the system and not from output. Option b is incorrect because drain removal follows a provider order once output has fallen over several days. Low output on a single check, in a drain that is not even holding suction, proves nothing about readiness. Option d is incorrect because closed surgical drains are not irrigated by the nurse; flushing one would push organisms toward the wound bed. The remedy here is to re-compress the reservoir and cap it while it stays flat.

Correct Answer: Head of bed elevated to forty-five degrees

Keeping the head of the bed elevated between thirty and forty-five degrees during the feeding, and for thirty to sixty minutes afterward, is the single strongest measure against aspiration in a tube fed client. Option b is incorrect because a flat position lets formula travel back up the esophagus and into the airway. Supine positioning during tube feeding is associated with markedly higher rates of pneumonia. Option c is incorrect because left side lying is used to pool gastric contents around the tip when aspirate cannot be obtained. It is a troubleshooting position, not the position for delivering a feeding. Option d is incorrect because fifteen degrees falls well short of the elevation needed. Gravity still favors reflux at that angle, and the head of the bed should be lowered only after the feeding is paused.

Correct Answer: I will flavor food with herbs and lemon.

Herbs, spices, lemon juice and vinegar add flavor without sodium, which is the substitution taught for any sodium restricted diet. It also helps the client whose taste has dulled and who would otherwise reach for salt. Option a is incorrect because sea salt and table salt are both sodium chloride and carry nearly the same sodium per teaspoon. The coarser grain changes texture and price, not the amount the client swallows. Option b is incorrect because canned soups are among the highest sodium items in an ordinary pantry, often carrying most of a day's allowance in one bowl. Processed and canned foods are the first thing limited. Option d is incorrect because most salt substitutes replace sodium with potassium chloride. Clients with heart failure often take potassium sparing diuretics or renin angiotensin blockers, and unsupervised use risks a dangerous rise in potassium.

Correct Answer: Stage four, because tendon is exposed

Glistening white tissue at the base of a full thickness wound is tendon, and exposed or palpable tendon, muscle, fascia, ligament, cartilage or bone defines stage four. Slough at the edge does not change that. Option b is incorrect because stage three stops at adipose tissue and excludes any deeper structure. Once tendon comes into view the wound has passed that boundary, whatever else the bed contains. Option c is incorrect because slough only forces the unstageable label when it hides how deep the wound goes. Here the nurse can see the deepest tissue, so the extent of loss is already confirmed. Option d is incorrect because moisture in the bed says nothing about depth. Partial thickness loss is the requirement for stage two, and a cavity reaching tendon is several layers past the dermis.

Correct Answer: Purulent drainage indicating wound infection

Thick, opaque drainage that is green, yellow, tan or brown and smells foul after cleansing is purulent. It is made of organisms, white cells and cellular debris, and it means the wound is infected. Option a is incorrect because serous drainage is clear, thin and straw colored plasma with no odor. Seeing it in the first days is reassuring, whereas the drainage described here is opaque, thick and colored. Option b is incorrect because bright red thin drainage means fresh blood is leaving an open vessel, which calls for pressure and prompt reporting. Green material contains no blood at all and points to a different problem. Option c is incorrect because a mix of plasma and a little blood looks pale pink and watery, and it belongs to the first day or two after closure. Neither its color nor its consistency matches what the nurse found.

Correct Answer: "No, the schedule stays every two hours."

A support surface redistributes pressure over a wider area but never eliminates it, so it does not replace repositioning. Intervals are individualized and should not routinely be stretched to four hours or more for an at risk client. Option a is incorrect because no mattress reduces interface pressure to zero. Time under load is the second half of the injury equation, and only repositioning shortens that half. Option c is incorrect because specialty surfaces differ widely and none of them licenses a blanket four hour interval. Guidelines allow two or three hourly turning on an appropriate surface, with longer gaps reserved for improving clients. Option d is incorrect because stretching to six hours is even further from the standard than the assistant proposed. Two hours of unrelieved pressure can already start tissue damage in a vulnerable client.

Correct Answer: "I will wipe front to back and catch midstream."

Wiping front to back keeps bowel organisms away from the meatus, and the middle portion of the stream is collected because the first portion flushes out the bacteria that normally live in the distal urethra. Option a is incorrect because that direction drags fecal flora forward onto the urethral opening. Each stroke also needs its own fresh wipe, so a single wipe used repeatedly simply spreads what it picked up. Option b is incorrect because the opening portion of the stream carries the organisms colonizing the lower urethra. A culture grown from it reports bacteria that were never in the bladder, and the client may be treated needlessly. Option d is incorrect because touching the sterile container to perineal skin contaminates it instantly. The cup is held clear in the stream, and only its outside is handled, so the inside stays sterile until the lid closes.

Correct Answer: Reactive hyperemia at the trochanter

Erythema that blanches under a fingertip and refills on release shows the microcirculation is intact. This is reactive hyperemia, a normal response to pressure relief, and it warns that the turning interval needs shortening. Option b is incorrect because a stage one injury is defined by erythema that does not blanch. Blood has leaked out of damaged capillaries there, so pressing the area produces no whitening at all. Option c is incorrect because deep tissue injury shows persistent deep red, maroon or purple discoloration that never blanches. The color described is ordinary red and it clears under the finger, ruling that category out. Option d is incorrect because moisture damage arises from urine, stool or sweat sitting against the skin, and it appears as diffuse maceration in folds. Nothing wet is described, and this redness sits on a bony prominence.

Correct Answer: Stage three, because adipose tissue is visible

Full thickness loss with adipose visible in the bed, often with granulation and rolled edges, defines stage three. No fascia, muscle, tendon, ligament, cartilage or bone is exposed, which would move it to stage four. Option a is incorrect because stage two is partial thickness with a viable pink moist bed and no visible fat. Seeing adipose tissue rules stage two out immediately, no matter how shallow the wound looks. Option b is incorrect because rolled edges, called epibole, occur in both stage three and stage four and do not raise the stage. Stage four requires exposed or palpable fascia, muscle, tendon or bone. Option c is incorrect because nothing hides this wound bed. Unstageable is reserved for a wound whose base is covered by slough or eschar, and here the nurse can see the deepest tissue clearly.

Correct Answer: Tissue that feels boggy and warmer than adjacent skin

Melanin masks erythema, so color is unreliable in darkly pigmented skin. Localized warmth, bogginess, pain and change from the client's own baseline tone are the findings that reveal early damage at this site. Option a is incorrect because prompt blanching and refill show that the microcirculation still works. That is reactive hyperemia, a reversible response to pressure relief rather than evidence of an injury forming. Option c is incorrect because generalized dryness and flaking describe xerosis, a common finding in aging skin. It calls for a moisturizer, not for the offloading plan an early pressure injury would trigger. Option d is incorrect because a shiny surface alone carries little weight when temperature matches the tissue around it. Temperature change, either warmer or cooler, is one of the strongest early clues available here.

Correct Answer: Restrict activity and notify the surgeon promptly

A sudden surge of pale pink serosanguineous drainage from an abdominal incision after a cough is the classic warning of impending dehiscence. The nurse limits activity, keeps the client still and reports the change so the wound can be evaluated. Option b is incorrect because waiting turns a warning into an emergency. Reinforcing gauze manages the fluid but leaves the client active, and this wound is at its weakest point with two strong risk factors already working against it. Option c is incorrect because a binder supports an incision but does not replace evaluation, and walking a client whose wound may be separating increases abdominal wall tension. Ambulation belongs in routine recovery, not in this moment. Option d is incorrect because irrigation is used to clean an open wound bed, and these edges are still approximated. Flushing an intact suture line adds no benefit, delays reporting, and drives fluid into tissue that is already compromised.

Correct Answer: Perform a bladder scan to measure volume

Suprapubic pressure with a rounded lower abdomen and no void after eight hours calls for measurement, not waiting. A bladder scan quantifies what is there and tells the nurse whether noninvasive measures or catheterization is needed. Option a is incorrect because hesitancy after removal is indeed expected, but this client has produced nothing at all and has a distended abdomen. Reassurance alone would leave a full bladder to keep stretching. Option b is incorrect because putting the catheter straight back requires an order and skips the assessment that decides whether it is needed. Privacy, an upright position and warm water often produce a void first. Option d is incorrect because more time is exactly what this bladder cannot afford. Sustained overdistension damages the detrusor and pushes pressure back toward the kidneys, and the findings already show the window has passed.

Correct Answer: Let the strips loosen and fall off themselves

Adhesive strips are left in place to support the incision and are allowed to lift and fall away on their own, usually within a week or so. Pulling them off early removes support from a line that is still weak. Option a is incorrect because removing them on the second day takes support away while collagen is still immature. They are meant to stay until the adhesive gives way, which is usually seven to ten days. Option b is incorrect because a closed incision holds only about eighty percent of normal tissue strength even when it looks healed. Heavy lifting is avoided for the period the surgeon specifies, or the repair can pull apart. Option c is incorrect because ultraviolet light permanently darkens an immature scar. New scar tissue is shielded from the sun for at least a year, with clothing or sunscreen, rather than deliberately exposed to it.

Correct Answer: Document the findings and continue routine incision care

Redness, warmth, swelling and mild pain at the incision during the first days are the cardinal signs of the normal inflammatory phase. With scant serous drainage and no systemic decline, the nurse records the findings and continues routine care. Option a is incorrect because a culture is taken when infection is suspected, and nothing here suggests it. Culturing expected inflammation grows surface colonizers, wastes resources and may lead to antibiotics the client does not need. Option c is incorrect because surgical site infection usually declares itself on the third to fifth day or later, with purulent drainage, spreading redness, worsening pain and fever. None of those features is present on this second day. Option d is incorrect because an approximated surgical incision is kept clean and dry, not occluded. Hydrocolloid is chosen for shallow open wounds needing a moist bed, and covering an incision with it would hide the site from inspection.

Correct Answer: Urinary retention with a full bladder

The palpable, dull, distended bladder is the discriminator. Urine is being produced normally and stored abnormally, which is retention. Anesthesia and opioids blunt detrusor contraction, and a bladder scan followed by drainage is the direction of care. Option a is incorrect because anuria means the kidneys are making essentially no urine, under about one hundred milliliters a day. A bladder full enough to palpate proves the kidneys are working perfectly well. Option b is incorrect because a client with poor renal perfusion has an empty bladder, not a distended one. Treating this as oliguria would send the nurse chasing fluids and blood pressure while the bladder keeps overfilling. Option d is incorrect because polyuria describes an excessive volume of urine actually passed, generally beyond two and a half liters daily. This client has passed none, so the finding fits the opposite end of the spectrum.