Not By the Hair On My Skinny Skin Skin
True or False: Donut pillows are recommended to prevent pressure ulcers/injury to the sacral area for immobile patients.
False!
Research now advises against the use of donut pillows because they actually concentrate pressure around the edges of the ring, cut off circulation, and can increase risk of skin breakdown rather than prevent it.
Current best practice emphasizes:
Pressure redistribution surfaces (specialized foam, gel, or air cushions/mattresses).
Frequent repositioning (every 2 hours or sooner if needed).
Good skin care (keeping skin clean, dry, moisturized).
Nutritional support and hydration.
Pain at McBurney's Point is associated with which of the following conditions?
A. Ulcerative Colitis
B. Appendicitis
C. Cholecystitis
D. Peptic Ulcer Disease
B - Appendicitis
McBurney's Point is located in the RLQ between the anterior iliac crest and the umbilicus.
True or False: Infections of the urinary system can be caused by Sexually Transmitted Infections (STIs).
True.
Specifically urethritis. However, any secondary infection in the body, including STIs, can contribute to infections of the urinary system.
Which medication does the nurse anticipate administering to a patient who has kidney stones due to high calcium?
A. Allopurinol
B. Furosemide
C. Hydrochlorothiazide
D. Magnesium
C - Hctz
Thiazide diuretics help reduce calcium excretion which lowers chance of calcium stone formation.
Your patient had a recent bowel resection and is on TPN. It has been 24 hours since the current bag of TPN was started. There is still 250mls in the bag. What is the appropriate action?
A. Let the remaining 250mls infuse and then hang a new bag with new tubing
B. Increase the rate of TPN so the 250mls will infuse quickly so it is not wasted
C. Remove the current bag of TPN and replace with a new bag and tubing.
D. Replace the bag with 10% dextrose solution
C
24 hours is the max amount of time a bag of TPN can safely infuse without increasing the risk of infection. Even if there is still fluid in the bag, replace with a new bag and tubing.
The nurse is caring for a patient who has been on biologic therapy (etanercept, adalimumab, infliximab) for plaque psoriasis. Which assessment finding requires immediate intervention?
A. Increased itching
B. Temperature 100 F
C. Presence of new plaque on legs
D. Expression of impaired self image
B - Temperature of 100.
These medications are immunosuppressants. It is important to address signs of infection immediately to avoid any life threatening problems.
Patients with Crohn's Disease will have ______________ while patients with Ulcerative Colitis will have ___________________.
1. 10-20 bloody stools per day
2. Alternating constipation and diarrhea
3. 5-6 fatty diarrhea stools per day
4. Abdominal pain that is relieved by having a bowel movement
A. 2 and 4
B. 3 and 1
C. 1 and 2
D. 4 and 3
B - 3 and 1
Patients with CD often have 5-6 fatty diarrhea stools each day while patients with UC can have 10-20 bloody stools with mucus each day.
When obtaining the health history of a 68 year old male patient who has a history of an enlarged prostate, which findings does the nurse consider significant? Select all that apply.
A. Distended bladder
B. Absence of bruit
C. Frequency of urination
D. Dribbling urine after voiding
E. Chemical exposure in the workplace
A, C, D
Distended bladder is concerning for urinary retention d/t not being able to completely empty the bladder. Frequency of urination is important to assess as patients with BPH need to urinate more often because they cannot fully empty their bladder. Dribbling after urination is a common symptom of BPH.
Which of the following medications is used for the treatment of pediculosis (lice)? Select all that apply.
A. Permethrin
B. Pyridium
C. Ivermectin
D. Malathion
A, C, D
Permethrin is also called Nix
Oral Ivermectin is used for resistant lice treatment
Malathion is called Ovide
Pyridium is used for pain management in UTI
What type of diet is crucial for wound healing?
A. High calorie
B. Low fat
C. Low residue
D. High protein
Protein is essential for tissue repair and wound healing. Testing albumin levels shows the serum protein in patients. Lower levels may indicate a degree of malnourishment.
Which assessment data regarding a lesion found on a 39 year old client who uses a tanning bed requires follow up? Select all that apply.
A. Symmetrical and light pink
B. Brownish-purple with irregular borders
C. Changed in shape since last appointment
D. 8mm wide and described as itching often
E. Regular border with fixed size and elevation
B - multiple colors (brown and purple) and irregular border
C - change in shape
D - >6mm in size
The nurse is teaching a patient with diverticulosis about nutrition. Which food choice should the patient be instructed to avoid?
A. Cucumber
B. Beans
C. Carrot
D. Radish
A - Cucumber
Cucumbers have seeds and seeds can become stuck in the pouches and lead to infection and inflammation.
A. Prepare the patient for lithotripsy
B. Encourage oral intake of fluids
C. Strain the urine and send urinalysis
D. Administer opioids as prescribed
D - Administer opioids as prescribed
Renal colic causes severe, acute pain; priority is rapid pain control (safety/physiologic need). After analgesia, proceed with fluids and diagnostics.
Prepare for lithotripsy – Not first-line for an acute episode; depends on stone size/location and provider plan.
Encourage oral fluids – Important, but not first in a patient with severe pain and N/V; may need IV fluids after analgesia.
Strain urine & send UA – Appropriate to identify passage/composition, but after stabilizing pain.
Which medication used for BPH treatment is considered to be a hazardous medication and can be absorbed through the skin?
A. Finasteride
B. Lasix
C. Proscar
D. Dutasteride
D - Dutasteride aka Avodart
This medication is used to mediate cell growth in the prostate gland, however it is also absorbed through the skin so pregnant women should avoid as it can cause birth defects.
_____________ wound healing occurs when wounds are left open because they are infected.
Tertiary or delayed closure
These wounds are left open to allow for frequent washouts, clearing infection, and debriding. They often require wound vac dressings.
When preparing to discharge a client who has a history of pediculosis, what teaching should the nurse provide? Select all that apply.
A. Nits can be removed with a fine tooth comb
B. Parasites eventually die off without treatment
C. Wash bed linens in hot water to remove lice and eggs
D. Lice can live on clothing items and any surface that is covered by fabric
E. Lice can infest any place on the body with hair, including eyelashes and axillae.
A, C, D, E
B is incorrect because they will not die without treatment.
Which assessment finding is indicative of peritonitis?
A. WBCs 8,000
B. Rigid, board-like abdomen
C. RUQ pain that extends to the back or shoulder
D. Bradycardia
B - Rigid, board-like abdomen
Peritonitis caused by perforation of a peptic ulcer, appendix rupture, or any reason that involves introduction of fluid into the sterile abdominal cavity causes a hard, rigid, board like abdomen followed by severe pain.
When assessing a client with acute glomerulonephritis, which question will the nurse ask to determine if the client is following best practice to slow progression of kidney damage?
A. "Do you avoid contact sports while you are taking cyclosporine?"
B. "How are you evaluating the amount of daily fluid you drink?"
C. "Have you contacted anyone from our dialysis support services?"
D. "Have you increased your protein intake to promote healing of the damage nephrons?"
B - B. "How are you evaluating the amount of daily fluid you drink?"
Remember with glomerulonephritis, patients can become edematous and have fluid overload. These patients will need to closely monitor their fluid intake.
Contact sports and cyclosporine are not an issue for AGN, dialysis is not needed until there is an AKI or complete renal failure, and patients need to decrease their protein intake with AGN. Remember the damage to the glomeruli causes protein spilling.
Which medication should be avoided in patients with gastroenteritis?
A. Loperamide
B. Normal Saline infusion
C. Tums
D. Insulin
A - Loperamide (Imodium) is an antidiarrheal and should be avoided in cases of gastroenteritis
The nurse recognizes that which of the following is an example of nonmechanical bowel obstruction?
A. Intusseception
B. Volvulus (twisted bowel loops)
C. Paralytic ileus d/t opioid use
D. Foreign object
C - Paralytic ileus d/t opioid use
Nonmechanical obstructions are things that interrupt normal peristalsis of the bowel. The bowel cannot push contents through due to narcotic use, electrolyte imbalance such as hypokalemia, or general anesthesia.
Mechanical obstructions are a result of something blocking the movement of contents such as twisting of the bowels, foreign bodies, adhesions, hernias, and tumors.
_____________ is a skin infection caused by mites. These mites burrow into the skin causing itching and linear lines where they burrow.
Scabies
A nurse is caring for a client 2 hours after an ERCP for gallstone extraction. Which finding requires immediate intervention?
A. Sore throat and hoarseness
B. Abdominal bloating with passage of flatus
C. Epigastric pain radiating to the back with nausea and vomiting
D. Drowsiness and short-term memory loss
C - this finding suggests post ERCP pancreatitis, an uncommon but serious complication.
A, B, and D are expected findings after an ERCP. Sore throat and hoarseness d/t the EGD, abdominal bloating and passing gas is typical after this procedure, and drowsiness with short term memory loss is d/t the use of anesthesia.
The nurse is teaching a client newly diagnosed with a polycystic kidney disease (PKD) about home management to slow disease progression. Which statement by the client indicates correct understanding?
A. “I will check my blood pressure every day and limit salt in my diet.”
B. “I’ll take ibuprofen for my flank pain because it’s stronger than acetaminophen.”
C. “I’m going to increase my protein intake to protect my kidneys.”
D. “I don’t need to seek care for headaches unless I stop making urine.”
A - patients with PKD develop hypertension which needs to be closely monitored. Checking BP each day and monitoring their salt intake indicate correct understanding.
NSAIDs can reduce renal perfusion and worsen kidney function; acetaminophen is preferred unless contraindicated. High protein can increase renal workload. Sudden severe headache can indicate intracranial aneurysm (higher risk in PKD) and needs urgent evaluation!!!
The nurse provides discharge teaching to a client prescribed tolterodine (Detrol) for urge urinary incontinence. Which statement by the client indicates correct understanding of the teaching?
A. “I will avoid taking over-the-counter antihistamines unless my provider approves.”
B. “If my mouth gets dry, I should stop taking the medication right away.”
C. “This medicine will fix my leaking when I cough or sneeze.”
D. “I’ll take an extra dose only on days when my urgency is worse.”
A - “I will avoid taking over-the-counter antihistamines unless my provider approves.”
Tolterodine is an antispasmodic medication that is used for incontinence however it is also an anticholinergic; OTC antihistamines (many are anticholinergic) can increase side effects (urinary retention, confusion, constipation, dry mouth, blurry vision).
Dry mouth is common; manage with sugar-free gum/candy, frequent sips, good oral care. Don’t stop without provider guidance. Tolterodine treats urge incontinence (overactive bladder), not stress incontinence from coughing/sneezing. It is taken regularly as prescribed (not PRN). Overuse increases anticholinergic adverse effects.
Which of the following can cause clay or pale colored stool? Select all that apply.
A. Barium enema
B. Crohn's Disease
C. Bowel Obstruction
D. Acute Cholecystitis d/t stones
A and D
Barium enemas are white in color so having light/pale colored stools afterwards is expected.
Acute cholecystitis due to gallstones can cause clay colored stools due to blockage of bile duct. If bile cannot reach the intestines, stools lose their normal brown color.