NUR233 FINAL EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
In which stage does a pressure injury show a partial loss in the thickness of the
dermis?
STAGE II
The nurse is caring for a bedbound patient with a pressure injury of the coccyx
and a Braden score of 9. Which nursing action is the priority?
Position the head of the bed less than 30 degrees
The nurse is caring for a patient with a pressure injury that is a shallow, open
ulcer with a red-pink wound bed, without slough. How should the nurse
document the finding?
Stage II
The nurse receives hand-off report on a group of patients. Which patient is the
highest risk for developing pressure injury? Select all that apply.
A young adult who is quadriplegic
An older adult who is bedridden and diaphoretic
A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool
A middle-aged adult with a Braden scale score of 7
The wound care nurse is educating a group of nursing students about the stages
of a pressure injury. Which statement is correct when describing a stage III
pressure injury?
Stage III is full-thickness skin loss with exposure to adipose tissue
,The nurse is caring for an older adult who is malnourished. The patient is
confused and has bilateral leg contractures. The patient is incontinent of urine
and on aspiration precautions. What should be included in the plan of care?
Select all that apply.
Apply barrier cream to the skin as needed
Keep linens and gowns dry and wrinkle free
Use a wedge pillow to keep the legs apart
The home care nurse assesses a stage I pressure injury on an older adult patient
who has limited mobility from a stroke. What should the nurse include when
educating the patient's daughter about her care? Select all that apply.
Deliver high protein shakes twice a day
Exercise the extremities actively and passively every 4 hours
Be sure she changes positions at least every 2 hours
Use pillows to pad all bony prominences
A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the
coccyx. The site is painful to palpation. How should the nurse document the
stage of this wound?
Stage II
This nurse is receiving hand-off report for these patients. Which patient is the
highest risk for pressure injury?
A. 73 Female who weighs 82 pounds; stress incontinence
B. 92 female with heart failure, 3+ edema, ambulatory
,C. 5 month male with croup
D. 86 male with dementia and shingles. wanders the halls
A
The nurse is caring for a patient being discharged from the urgent care with the
diagnosis of bacterial rhinosinusitis. What should the nurse include in the
instructions?
Notify the provider if you experience neck stiffness, severe headache, or light sensitivity
The nurse is providing a workshop at an adult community center about
obstructive sleep apnea (OSA). What information should be included as correct?
Select all that apply.
It results in narrowing of one or more sites of the upper airway, resulting in intermittent
breathing patterns
It can increase intrathoracic pressure and lead to decreased tidal volume for several
breaths or periods of apnea
It can be treated by using continuous positive airway pressure (CPAP)
The nurse is talking with a friend who is experiencing allergic rhinitis. What could
the nurse share as possible causes? Select all that apply
Cow's milk
Angiotensin-coverting enzyme (ACE) inhibitors
Animal dander
The nurse is asking family health history information of a young adult. The
patient's father has obstructive sleep apnea (OSA). Which statement by the client
requires additional education?
, I enjoy drinking with my friends; we usually have a few beers each evening
Which respiratory disorder can be diagnosed with the help of polysomnography?
Obstructive sleep apnea (OSA)
A patient comes to the clinic with a 7-day history of purulent nasal drainage,
facial pressure, and pain. He has been using oral and nasal decongestants, and
over-the-counter pain and sleep medicine. He says, "I am miserable!" What is the
nurse's priority assessment?
Obtain a temperature
Rationale: fever could indicate the severity of the infection
The provider is sending the patient for polysomnography testing. What
symptoms support the need for this? Select all that apply
Daytime sleepiness
rationale: daytime sleepiness is associated with OSA
Loud snoring
rationale: loud snoring is a sign that a patient has OSA
Insomnia
rationale: a pt with OSA suffers from insomnia
The nurse is caring for a patient who experienced a laryngeal trauma from a self-
aborted suicide attempt by hanging. What is a priority action?
Confirm that emergency tracheostomy or intubation equipment is kept nearby
rationale: tracheostomy or intubation equipment should be kept at the bedside of a pt in
case the airway is occluded from tissue edema
COMPLETE SOLUTIONS VERIFIED
In which stage does a pressure injury show a partial loss in the thickness of the
dermis?
STAGE II
The nurse is caring for a bedbound patient with a pressure injury of the coccyx
and a Braden score of 9. Which nursing action is the priority?
Position the head of the bed less than 30 degrees
The nurse is caring for a patient with a pressure injury that is a shallow, open
ulcer with a red-pink wound bed, without slough. How should the nurse
document the finding?
Stage II
The nurse receives hand-off report on a group of patients. Which patient is the
highest risk for developing pressure injury? Select all that apply.
A young adult who is quadriplegic
An older adult who is bedridden and diaphoretic
A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool
A middle-aged adult with a Braden scale score of 7
The wound care nurse is educating a group of nursing students about the stages
of a pressure injury. Which statement is correct when describing a stage III
pressure injury?
Stage III is full-thickness skin loss with exposure to adipose tissue
,The nurse is caring for an older adult who is malnourished. The patient is
confused and has bilateral leg contractures. The patient is incontinent of urine
and on aspiration precautions. What should be included in the plan of care?
Select all that apply.
Apply barrier cream to the skin as needed
Keep linens and gowns dry and wrinkle free
Use a wedge pillow to keep the legs apart
The home care nurse assesses a stage I pressure injury on an older adult patient
who has limited mobility from a stroke. What should the nurse include when
educating the patient's daughter about her care? Select all that apply.
Deliver high protein shakes twice a day
Exercise the extremities actively and passively every 4 hours
Be sure she changes positions at least every 2 hours
Use pillows to pad all bony prominences
A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the
coccyx. The site is painful to palpation. How should the nurse document the
stage of this wound?
Stage II
This nurse is receiving hand-off report for these patients. Which patient is the
highest risk for pressure injury?
A. 73 Female who weighs 82 pounds; stress incontinence
B. 92 female with heart failure, 3+ edema, ambulatory
,C. 5 month male with croup
D. 86 male with dementia and shingles. wanders the halls
A
The nurse is caring for a patient being discharged from the urgent care with the
diagnosis of bacterial rhinosinusitis. What should the nurse include in the
instructions?
Notify the provider if you experience neck stiffness, severe headache, or light sensitivity
The nurse is providing a workshop at an adult community center about
obstructive sleep apnea (OSA). What information should be included as correct?
Select all that apply.
It results in narrowing of one or more sites of the upper airway, resulting in intermittent
breathing patterns
It can increase intrathoracic pressure and lead to decreased tidal volume for several
breaths or periods of apnea
It can be treated by using continuous positive airway pressure (CPAP)
The nurse is talking with a friend who is experiencing allergic rhinitis. What could
the nurse share as possible causes? Select all that apply
Cow's milk
Angiotensin-coverting enzyme (ACE) inhibitors
Animal dander
The nurse is asking family health history information of a young adult. The
patient's father has obstructive sleep apnea (OSA). Which statement by the client
requires additional education?
, I enjoy drinking with my friends; we usually have a few beers each evening
Which respiratory disorder can be diagnosed with the help of polysomnography?
Obstructive sleep apnea (OSA)
A patient comes to the clinic with a 7-day history of purulent nasal drainage,
facial pressure, and pain. He has been using oral and nasal decongestants, and
over-the-counter pain and sleep medicine. He says, "I am miserable!" What is the
nurse's priority assessment?
Obtain a temperature
Rationale: fever could indicate the severity of the infection
The provider is sending the patient for polysomnography testing. What
symptoms support the need for this? Select all that apply
Daytime sleepiness
rationale: daytime sleepiness is associated with OSA
Loud snoring
rationale: loud snoring is a sign that a patient has OSA
Insomnia
rationale: a pt with OSA suffers from insomnia
The nurse is caring for a patient who experienced a laryngeal trauma from a self-
aborted suicide attempt by hanging. What is a priority action?
Confirm that emergency tracheostomy or intubation equipment is kept nearby
rationale: tracheostomy or intubation equipment should be kept at the bedside of a pt in
case the airway is occluded from tissue edema
