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NR 493 FUNDAMENTALS POST EXAM 2023-2024
QUESTIONS AND CORRECT DETAILED ANSWERS
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COMPLETE SOLUTION
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la
tz
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Sp
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List four (4) examples of a primary skin lesion including description and example of each.
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Provide an example of appropriate documentation of the integumentary system.
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Sp
1. Macule: A nonpalpable skin color change that is smaller than 1cm. Example: freckle
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2. Papule: A palpable, solid elevated lesion; 1 cm or less in size. Example: elevated
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nevus
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3. Pustule: A pus filled lesion that can be the result of an infection of a vesicle, and
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may vary in size. Example: acne
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4. Nodule: A palpable, solid elevated lesion that lies deep in the dermis; 1-2 cm in size.
Example: wart
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Sp
Documentation: Skin is pink, dry, and warm; free from lesions and is intact; brisk skin
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turgor and moist mucous membranes; nail beds are pink and symmetrical, free from
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tz
clubbing, <3 second cap refill; hair brown and evenly distributed across the body;
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Sp
Peripheral pulses +2 x4; No edema.
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la
List three (3) actions to take during the analysis or data collection step.
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1. Introduce self and various parts of the exam to the patient
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2. Use therapeutic communication techniques to build rapport with patient as the
la
exam progresses
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3. Reduce distractions, such as environmental noises.
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Sp
ne
la
The nurse discovers a fire on the unit. After following the proper steps included in RACE,
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the nurse begins to extinguish the fire. What is RACE? What are the proper steps for using
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a fire extinguisher?
a
- RACE is Rescue, Alarm, Contain, Extinguish; Rescue any patients from the
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l
immediate area, Alarm EMS by pulling the fire alarm, Contain the fire by closing the
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Sp
doors, Extinguish if safe to do so.
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- Proper steps to using a fire extinguisher are PASS (Pull the pin, Aim at the base of
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the fire, Squeeze the handle, Sweep from side to side.
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Sp
la
Sp
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A nurse is providing discharge education to a client regarding home wound care. What
manifestations of wound infection should the nurse include in this education?
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- Keep the wound dry and clean. Cleanse area gently with sterile normal saline.
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Recover with sterile gauze square large enough to cover wound, and secure
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hypoallergenic tape.
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- Immediately report any signs or symptoms of infection. Signs of infection include:
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Sp
redness, swelling, tenderness, increased warmth, red streaks near wound, pus,
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discharge, foul odor, chills, or temperature higher than 100F.
la
- If soreness or pain causes discomfort, apply a cool pack or take prescribed pain
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Sp
medicine.
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A client has been diagnosed with Varicella. What type of tier transmission precaution is
la
tz
required? What protective equipment will be required for prevention of transmission?
sh
Sp
- Airborne, tier two precautions.
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- A private room, use of mask/respiratory protection device, negative pressure
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airflow room, if splashing is possible use full face protection.
sh
Sp
List at least five (5) priority considerations when performing a sterile dressing change.
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1. Hand hygiene
la
2. Avoid coughing, sneezing, and talking directly over sterile field
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3. Only sterile items may be in sterile field.
sh
Sp
4. Discard and sterile packages that are torn punctured or wet.
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5. Select a clean area above waist level in the patient’s environment to set up a sterile
la
field.
sh
Sp
Identify three (3) priority teaching points to include when educating a client to use a cane.
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1. Maintain two points of support on the ground at all times.
la
2. Keep the cane on the stronger side of the body.
tz
3. Move the cane forward, then move the weaker leg toward the cane, then advance
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Sp
stronger leg past the cane.
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A nurse is caring for a client receiving oxygen therapy. What is the expected reference
la
range when obtaining oxygen saturation level? Identify four (4) reasons the reference
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Sp
range may be lower.
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- The expected reference range for the oxygen saturation levels would be 95%-100%.
a
-Some of the reasons it may be low could be due to person with COPD, pneumonia,
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l
sh
pulmonary edema, or asthma.
Sp
ne
Describe tertiary prevention measures and provide one (1) example.
la
- Tertiary prevention aims to prevent the long term consequences of a chronic illness
sh
or disability and to support optimal functioning.
Sp
- One example of this is foot care for a person with Diabetes.
la
Sp
NR 493 FUNDAMENTALS POST EXAM 2023-2024
QUESTIONS AND CORRECT DETAILED ANSWERS
sh
COMPLETE SOLUTION
ne
la
tz
sh
Sp
ne
List four (4) examples of a primary skin lesion including description and example of each.
la
Provide an example of appropriate documentation of the integumentary system.
sh
Sp
1. Macule: A nonpalpable skin color change that is smaller than 1cm. Example: freckle
ne
2. Papule: A palpable, solid elevated lesion; 1 cm or less in size. Example: elevated
la
nevus
tz
sh
3. Pustule: A pus filled lesion that can be the result of an infection of a vesicle, and
Sp
ne
may vary in size. Example: acne
la
4. Nodule: A palpable, solid elevated lesion that lies deep in the dermis; 1-2 cm in size.
Example: wart
sh
Sp
Documentation: Skin is pink, dry, and warm; free from lesions and is intact; brisk skin
ne
turgor and moist mucous membranes; nail beds are pink and symmetrical, free from
la
tz
clubbing, <3 second cap refill; hair brown and evenly distributed across the body;
sh
Sp
Peripheral pulses +2 x4; No edema.
ne
la
List three (3) actions to take during the analysis or data collection step.
sh
1. Introduce self and various parts of the exam to the patient
Sp
ne
2. Use therapeutic communication techniques to build rapport with patient as the
la
exam progresses
tz
3. Reduce distractions, such as environmental noises.
sh
Sp
ne
la
The nurse discovers a fire on the unit. After following the proper steps included in RACE,
sh
the nurse begins to extinguish the fire. What is RACE? What are the proper steps for using
Sp
ne
a fire extinguisher?
a
- RACE is Rescue, Alarm, Contain, Extinguish; Rescue any patients from the
tz
l
immediate area, Alarm EMS by pulling the fire alarm, Contain the fire by closing the
sh
Sp
doors, Extinguish if safe to do so.
ne
- Proper steps to using a fire extinguisher are PASS (Pull the pin, Aim at the base of
la
the fire, Squeeze the handle, Sweep from side to side.
sh
Sp
la
Sp
, ne
A nurse is providing discharge education to a client regarding home wound care. What
manifestations of wound infection should the nurse include in this education?
sh
- Keep the wound dry and clean. Cleanse area gently with sterile normal saline.
ne
Recover with sterile gauze square large enough to cover wound, and secure
la
hypoallergenic tape.
tz
- Immediately report any signs or symptoms of infection. Signs of infection include:
sh
Sp
redness, swelling, tenderness, increased warmth, red streaks near wound, pus,
ne
discharge, foul odor, chills, or temperature higher than 100F.
la
- If soreness or pain causes discomfort, apply a cool pack or take prescribed pain
sh
Sp
medicine.
ne
A client has been diagnosed with Varicella. What type of tier transmission precaution is
la
tz
required? What protective equipment will be required for prevention of transmission?
sh
Sp
- Airborne, tier two precautions.
ne
- A private room, use of mask/respiratory protection device, negative pressure
la
airflow room, if splashing is possible use full face protection.
sh
Sp
List at least five (5) priority considerations when performing a sterile dressing change.
ne
1. Hand hygiene
la
2. Avoid coughing, sneezing, and talking directly over sterile field
tz
3. Only sterile items may be in sterile field.
sh
Sp
4. Discard and sterile packages that are torn punctured or wet.
ne
5. Select a clean area above waist level in the patient’s environment to set up a sterile
la
field.
sh
Sp
Identify three (3) priority teaching points to include when educating a client to use a cane.
ne
1. Maintain two points of support on the ground at all times.
la
2. Keep the cane on the stronger side of the body.
tz
3. Move the cane forward, then move the weaker leg toward the cane, then advance
sh
Sp
stronger leg past the cane.
ne
A nurse is caring for a client receiving oxygen therapy. What is the expected reference
la
range when obtaining oxygen saturation level? Identify four (4) reasons the reference
sh
Sp
range may be lower.
ne
- The expected reference range for the oxygen saturation levels would be 95%-100%.
a
-Some of the reasons it may be low could be due to person with COPD, pneumonia,
tz
l
sh
pulmonary edema, or asthma.
Sp
ne
Describe tertiary prevention measures and provide one (1) example.
la
- Tertiary prevention aims to prevent the long term consequences of a chronic illness
sh
or disability and to support optimal functioning.
Sp
- One example of this is foot care for a person with Diabetes.
la
Sp
