NSG 3100 Final Exam Questions and Answers
A client has a pressure ulcer with a shallow, partial skin
thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry gauze
3. Hydrocolloid
4. No dressing is indicated - ✔✔✔Answer: 3. Rationale: Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with
significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A
dressing is needed to protect the wound and enhance healing. Cognitive Level: Applying. Client Need:
Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-11
A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate
nursing diagnosis would be _____________. - ✔✔✔Answer: Because a malnourished client with a
wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others
may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.
Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosing.
Learning Outcome: 31-7.
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the
following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
4. Absent posterior tibial and pedal pulses - ✔✔✔Answer: 4. Rationale: The posterior tibial and pedal
pulses in the foot are considered peripheral and at least one of them should be palpable in normal
individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3:
Apical and carotid pulses are central and not peripheral. Cognitive Level: Analyzing. Client Need: Health
Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
After teaching a client and family strategies to prevent infection prevention, which statement by the
client would indicate effective learning has occurred?
1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day."
, 2. "We must wash or peel all raw fruits and vegetables
before eating."
3. "A wound or sore is not infected unless we see it
draining pus."
4. "We should not share toothbrushes but it is OK to share towels and washcloths." - ✔✔✔Answer: 2.
Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be
washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant
organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk
of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness,
swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not
share washcloths or towels (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care
Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5.
An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and
the inability to move self or maintain position unaided. The nurse determines that which sites are most
appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery - ✔✔✔Answer: 3, 4, and 5. Rationale: For this client, the nurse could take an axillary,
tympanic, or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral
route is not recommended (option 1). Although the rectal route could be used, it would require
unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-1.
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from
scratching an allergic rash is
1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
A client has a pressure ulcer with a shallow, partial skin
thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
1. Alginate
2. Dry gauze
3. Hydrocolloid
4. No dressing is indicated - ✔✔✔Answer: 3. Rationale: Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with
significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A
dressing is needed to protect the wound and enhance healing. Cognitive Level: Applying. Client Need:
Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-11
A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate
nursing diagnosis would be _____________. - ✔✔✔Answer: Because a malnourished client with a
wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others
may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.
Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosing.
Learning Outcome: 31-7.
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the
following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
4. Absent posterior tibial and pedal pulses - ✔✔✔Answer: 4. Rationale: The posterior tibial and pedal
pulses in the foot are considered peripheral and at least one of them should be palpable in normal
individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3:
Apical and carotid pulses are central and not peripheral. Cognitive Level: Analyzing. Client Need: Health
Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
After teaching a client and family strategies to prevent infection prevention, which statement by the
client would indicate effective learning has occurred?
1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day."
, 2. "We must wash or peel all raw fruits and vegetables
before eating."
3. "A wound or sore is not infected unless we see it
draining pus."
4. "We should not share toothbrushes but it is OK to share towels and washcloths." - ✔✔✔Answer: 2.
Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be
washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant
organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk
of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness,
swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not
share washcloths or towels (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care
Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5.
An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and
the inability to move self or maintain position unaided. The nurse determines that which sites are most
appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery - ✔✔✔Answer: 3, 4, and 5. Rationale: For this client, the nurse could take an axillary,
tympanic, or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral
route is not recommended (option 1). Although the rectal route could be used, it would require
unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-1.
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from
scratching an allergic rash is
1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
