NR-224 Fundamentals – Skills - Set 5 - Part 2

Correct Answer: Applying barrier cream after perineal care

Bathing, perineal care and applying a prescribed barrier product are standardized tasks an assistant may perform on a stable client. The nurse still assesses the skin, interprets what the assistant reports and adjusts the plan. Option a is incorrect because scoring a risk tool requires judgment about sensory perception, nutrition and mobility. That judgment sits with the licensed nurse, who also decides what the resulting number means for the plan. Option b is incorrect because staging is an assessment act and is never delegated at any level of experience. An assistant may report seeing an open area, but naming the depth belongs to the nurse. Option c is incorrect because client and family education is a nursing responsibility that carries accountability for what is understood. Assistants can reinforce a demonstration, yet they cannot deliver or evaluate the teaching itself.

Correct Answer: Stage two, since the dermis is exposed

Partial thickness loss with a viable pink moist bed, or an intact or ruptured serum filled blister, defines stage two. The absence of fat, granulation, slough and eschar confirms the loss stopped within the dermis. Option b is incorrect because stage one requires unbroken skin showing non blanchable erythema. An open area over the coccyx means the epidermis has already been lost, which moves the injury past that category. Option c is incorrect because being open says nothing about depth. Stage three demands visible adipose tissue in the bed, and this bed shows living dermis instead, which places it one level shallower. Option d is incorrect because the blister that signals deep tissue injury is blood filled and dark, not serum filled and clear. Deep tissue injury also brings persistent maroon or purple discoloration, which is absent here.

Correct Answer: Use barrier cream and a lift sheet

A low moisture score calls for prompt cleansing and a barrier product, while a low friction and shear score calls for lifting rather than dragging. Matching the intervention to the deficient subscale is how the score drives the plan. Option a is incorrect because protein supplementation and weight tracking address the nutrition subscale, which is not where this client lost points. Those measures matter generally but leave both identified deficits untouched. Option b is incorrect because hydration and joint exercises support activity and mobility rather than moisture control or safe handling. Neither one stops urine sitting against skin, and neither one prevents the client sliding down the bed. Option c is incorrect because a hydrocolloid is a treatment dressing for an existing wound, and no wound has been described. Floating the heels is sound prevention, yet it answers neither of the two failing subscales.

Correct Answer: "I will avoid caffeine and lengthen the voiding intervals."

Caffeine is both a diuretic and a direct bladder irritant, and bladder training gradually stretches the interval between voids so the detrusor stops contracting at low volumes. Both are core treatments for an overactive bladder. Option a is incorrect because severe fluid restriction concentrates the urine, and concentrated urine irritates the bladder and worsens urgency. Total daily intake is maintained; only the last two or three hours before bed are trimmed. Option c is incorrect because rushing raises abdominal pressure and jolts an already contracting bladder, which makes leakage on the way more likely. The taught response is to stop, contract the pelvic floor, and walk calmly. Option d is incorrect because a brief contains urine but changes nothing about why the bladder contracts. Products are a containment measure that belong alongside a continence program, never as a replacement for one.

Correct Answer: Primary intention with minimal scarring

Edges that have been brought together and held with staples heal by primary intention. Tissue loss is minimal, epithelium bridges a thin line within days, infection risk is lowest, and the result is a fine scar. Option b is incorrect because secondary intention applies to wounds deliberately left open, such as a pressure injury or an abscess cavity. Those fill from the base upward with granulation tissue and then contract, which takes weeks. Option c is incorrect because the surgeon would have left this wound open on purpose, packed it, and closed it days later once contamination was controlled. Tertiary intention describes that delayed closure, not a wound closed immediately. Option d is incorrect because only the epidermis regenerates. A surgical incision passes through the dermis, and dermal tissue repairs itself with disorganized collagen rather than regenerating, so a scar always forms along the closure line.

Correct Answer: Zinc, needed for healing and taste

Zinc is a cofactor for collagen formation and protein synthesis, and it is required for normal taste and smell. Delayed wound healing, blunted taste and hair loss together point to zinc depletion. Option a is incorrect because too little iodine enlarges the thyroid gland and slows metabolism. Goiter, cold intolerance, weight gain and fatigue are the findings, and none of them involve the wound bed. Option b is incorrect because selenium works inside antioxidant enzymes, and its deficiency is rare in the United States. When it does occur the target organ is the heart, producing a cardiomyopathy. Option d is incorrect because fluoride hardens tooth enamel and nothing more. A shortage of it shows up as dental caries, while an excess mottles the enamel, so neither state affects taste or healing.

Correct Answer: An elderly, hypotensive, incontinent client with poor intake

Risk factors compound through tissue tolerance. Age, hypotension, moisture from incontinence and poor nutrition each lower the oxygen and substrate reaching compressed tissue, so this client breaks down at pressures another client would tolerate. Option b is incorrect because immobility alone in a young, well perfused, well nourished person carries far less risk. A healed forearm fracture places no load on the sacrum, heels or trochanters at all. Option c is incorrect because sitting up for meals means this client changes position independently and relieves pressure without help. Independent movement is the strongest protection there is against tissue ischemia. Option d is incorrect because walking with an assistive device shows preserved mobility, which outweighs the extra load that higher body mass adds. This client needs skin fold care rather than a specialty mattress.

Correct Answer: The wound bed shows healthy granulation tissue

Beefy red, moist, granular tissue that bleeds easily is granulation tissue, the new vascular connective tissue built during the proliferative phase. It signals healing on track, and the nurse protects it from drying and from trauma at each change. Option a is incorrect because slough is yellow, tan, gray or white, and it is stringy, moist and fibrinous rather than granular. Its color and texture are nothing like the red bumpy surface described here. Option b is incorrect because dying tissue appears black, brown or tan and feels dry, hard and leathery, or looks gray and dull. A richly vascular bed that bleeds when touched is the opposite of necrosis. Option c is incorrect because infection shows itself through purulent drainage, odor after cleansing, spreading periwound redness, increasing pain and friable dull granulation. Slight bleeding from a healthy vascular bed is expected and is not a reason to culture.

Correct Answer: A client with extensive full thickness burns

Extensive burns drive a hypermetabolic catabolic state in which the body breaks down its own skeletal muscle for fuel, so nitrogen excreted in urine exceeds nitrogen taken in. That defines negative nitrogen balance. Option a is incorrect because pregnancy builds new maternal and fetal tissue, which places the client in positive nitrogen balance whenever protein intake is adequate. Anabolic states retain more nitrogen than they excrete. Option b is incorrect because rapid adolescent growth is the classic example of anabolism. Tissue is being laid down faster than it is broken down, and the teenager who eats enough stays in positive balance. Option d is incorrect because surgery alone does not guarantee catabolism. A client who is taking in full meals is meeting the raised protein demand of healing and is building tissue rather than consuming it.

Correct Answer: The bridge of the nose

A mask strap presses its own outline into the skin, and the bridge of the nose carries the most pressure with the least padding. The nurse inspects under and around every device each shift. Option a is incorrect because the area behind the ears is threatened by nasal cannula tubing or by the elastic of a cervical collar. A full face mask rests on the front of the face. Option c is incorrect because nares and septum damage comes from a nasogastric tube or nasal prongs sitting inside the nostril. This mask covers the outside of the nose rather than entering it. Option d is incorrect because injury at the mouth corners is typical of an endotracheal tube and its securing device. Damage to the lip and oral mucosa itself cannot be staged, while the surrounding skin is staged normally.

Correct Answer: Describe food positions using a clock face

Naming food positions as though the plate were a clock face lets the client locate each item and eat independently. Independence is the goal, and the nurse also states where the cup and utensils sit. Option a is incorrect because a client who is blind and otherwise well can eat unaided once the tray has been described. Taking over the task removes control at a meal and is more restrictive than needed. Option b is incorrect because crowding the dishes together makes them harder to tell apart and easy to knock over. Items are left in a consistent arrangement and named, so the client can reach for them confidently. Option d is incorrect because texture modification is prescribed for a chewing or swallowing problem, and blindness is neither. Pureeing this client's meal reduces its appeal and its intake while solving nothing about vision.

Correct Answer: The client in acute retention with a distended bladder

Acute urinary retention or bladder outlet obstruction heads the list of accepted indications, because the bladder must be drained to relieve pain and protect the kidneys from back pressure. The other three are convenience, not indication. Option a is incorrect because using a catheter to manage incontinence is named specifically as inappropriate. Skin protection comes from prompt cleansing, a barrier product and a toileting program, not from an indwelling tube. Option b is incorrect because a client able to void voluntarily should give a clean-catch midstream specimen. Catheterizing for diagnostics in someone who can urinate is on the list of uses to avoid. Option c is incorrect because frequent call bells describe a staffing frustration rather than a clinical problem. Answering promptly, offering a bedside commode and scheduling toileting solve it without adding daily infection risk.

Correct Answer: Remove the foam and apply a moist dressing

Foam left in a sealed wound without suction for longer than about two hours becomes a warm anaerobic pocket. The nurse takes the foam out, covers the wound with a moist dressing, notifies the provider and documents the interruption. Option a is incorrect because restarting suction over foam that has sat idle for hours pulls whatever has been growing under the drape deeper into the tissue. The dressing has to come off and be replaced before therapy resumes. Option c is incorrect because the pressure setting belongs to the prescription and is never adjusted by the nurse to silence an alarm. Raising it also does nothing about foam that has already been sitting in a sealed wound. Option d is incorrect because an occlusive drape with no suction beneath it is the one situation this system must never be left in. Waiting until the scheduled change would extend an interruption that is already too long.

Correct Answer: Vitamin C, needed for collagen synthesis

Bleeding swollen gums, petechiae, easy bruising and a wound that will not close are the picture of scurvy. Vitamin C is required for collagen synthesis, so both capillary walls and healing tissue fail without it. Option b is incorrect because vitamin A deficiency announces itself in the eye first. Night blindness, a dry conjunctiva and later corneal damage appear, along with rough dry skin, not gum bleeding. Option c is incorrect because too little vitamin D impairs calcium absorption and bone mineralization, producing rickets in children and osteomalacia in adults. Bone pain and deformity are the findings, and the gums are unaffected. Option d is incorrect because vitamin E protects red cell membranes as an antioxidant, and its deficiency shows up as hemolytic anemia or neuropathy. Excess vitamin E, not shortage, raises bleeding risk on anticoagulants.

Correct Answer: Setting up the tray and recording intake

Setting up a tray, opening containers, positioning the client and recording how much was eaten are routine tasks with predictable outcomes, which makes them appropriate for assistive personnel once the swallow has been screened. Option a is incorrect because judging tolerance is evaluation, the step of the nursing process that stays with the nurse. Assistive personnel report what they saw, such as coughing or a refused tray, and the nurse interprets it. Option c is incorrect because client and family teaching is a licensed nurse responsibility. Reinforcing a point already taught may be shared, but the original instruction about aspiration risk requires assessment of what the family understands. Option d is incorrect because texture is chosen by the speech language pathologist and the provider, and the nurse evaluates how the client manages it. Unlicensed staff carry out the ordered texture and never change it.

Correct Answer: Report the wasting and request a dietitian

Fluid retained in the abdomen adds weight without adding tissue, so body mass index looks normal while lean mass is being lost. The physical findings and weak grip are the reliable data and warrant referral. Option a is incorrect because body mass index is a screening number built from height and weight alone. It cannot separate muscle from fat or from fluid, so calling it reassuring here hides genuine depletion. Option b is incorrect because the scale is not in error. Repeating the measurement produces the same number and delays care, since the problem lies in what the number includes rather than in how it was obtained. Option c is incorrect because waiting worsens the deficit. Ascites in cirrhosis can persist for months, and protein calorie depletion in liver disease progresses during that time, so nutrition support belongs at the front of the plan.

Correct Answer: "Ring cushions cut off blood flow inside the opening."

A ring cushion concentrates pressure in a circle around the hole and obstructs venous return from the tissue inside it, causing the very injury it was meant to prevent. A redistributing foam or gel cushion is used instead. Option a is incorrect because frequent weight shifts do not cancel the ring's effect on the tissue trapped in the middle. Endorsing the device would leave the family confident in something that causes harm. Option b is incorrect because even brief sitting on a ring loads the rim heavily and strangles circulation in the center. There is no safe duration for a device that is not recommended at all. Option d is incorrect because healed skin over a former injury site keeps only about eighty percent of its original strength. Putting a ring cushion under that scar makes breakdown more likely, not less.

Correct Answer: Aspirate from the disinfected sampling port

Fresh bladder urine is aspirated with a sterile syringe from the sampling port after the port has been scrubbed and allowed to dry. Aspirating rather than disconnecting keeps the closed drainage system intact. Option b is incorrect because urine sitting in the bag has been outside the body for hours, and bacteria multiply rapidly in it. A bag sample reports organisms that were never present in the bladder. Option c is incorrect because breaking the junction between catheter and tubing opens a direct path for organisms to travel up the lumen into the bladder. The closed system is not opened for a specimen. Option d is incorrect because pulling a working catheter to get a sample subjects the client to a second invasive insertion for no reason. Every insertion carries urethral trauma and adds another chance to introduce organisms.

Correct Answer: Grilled chicken, broccoli and citrus fruit

Healing needs protein for collagen and immune cells and vitamin C for the cross linking that gives collagen its strength. Chicken supplies the protein while broccoli and citrus supply vitamin C, so this plate serves both needs. Option a is incorrect because this meal delivers refined carbohydrate and fat with almost no protein and no vitamin C. Calories alone keep weight on but give the body no substrate from which to build collagen. Option b is incorrect because rice and applesauce are carbohydrate foods, and iced tea adds fluid but nothing else. A client rebuilding tissue after a large wound loses protein in the exudate and needs it replaced. Option d is incorrect because cream soup and crackers are mostly starch, fat and sodium, and a soft drink contributes sugar. Nothing on this tray supplies the amino acids or the vitamin C that new tissue requires.

Correct Answer: "I will lay a pillow lengthwise under each calf."

A pillow running lengthwise under the calf suspends the entire heel in the air with no contact at all. Keeping a slight bend at the knee avoids pressure on the popliteal vessels. Option a is incorrect because an improvised roll under the heel simply relocates the load onto a smaller, harder surface. Rolled towels and fluid bags are specifically discouraged as offloading devices. Option b is incorrect because a pillow placed under the ankles leaves the calcaneus resting on the mattress. The support has to sit along the whole calf if the heel is to float free. Option c is incorrect because rubbing a bony prominence damages capillaries that are already compromised, and massage over pressure points is no longer taught. Lotion may soften dry skin but it removes no pressure.