NR-224 Fundamentals – Skills - Set 5 - Part 3

Correct Answer: Undermining from three to seven o'clock

Undermining is tissue loss that extends laterally under an intact skin edge over a broad area, so it is recorded with the range of clock positions it spans. Twelve o'clock is always the client's head. Option a is incorrect because tunneling is a narrow channel running in one direction away from the wound, and it is documented at one clock position. A finding sweeping across four hours of the clock face is not a tunnel. Option c is incorrect because a sinus tract is another name for tunneling, so this entry repeats the same error and also loses the width of the defect. Recording one position would understate how far the damage reaches. Option d is incorrect because epibole describes wound edges that have rolled under and epithelialized on themselves, stopping the wound from closing. It is an edge finding seen on inspection, not a space measured with an applicator.

Correct Answer: Output below thirty milliliters in an hour

Less than thirty milliliters an hour in an adult is below the accepted floor and signals inadequate kidney perfusion, dehydration or obstruction. Assistive personnel measure and report the number; the nurse interprets what it means. Option b is incorrect because pale straw is the expected color of normal urine. Reporting it would flood the nurse with routine findings and blunt attention to the results that genuinely need action. Option c is incorrect because one liter daily sits inside the usual adult range of roughly one to two liters. That volume reflects a kidney that is filtering and a client who is drinking adequately. Option d is incorrect because a faint aromatic smell is what normal urine has. A foul or ammonia-like odor would be worth reporting, since it suggests infection or urine that has stood and broken down.

Correct Answer: An amorphous hydrogel dressing

Hydrogel is mostly water and donates moisture to the wound bed. Rehydrating dry adherent slough lets the body's own enzymes break it down, which is autolytic debridement, and the gel also soothes pain in a shallow wound. Option a is incorrect because alginate is built for heavy exudate and needs fluid to turn into gel. On a dry bed it stiffens, sticks to the slough and causes pain and bleeding when the nurse removes it. Option c is incorrect because foam earns its place by soaking up moderate to heavy drainage and cushioning bony areas. This wound produces almost nothing, so foam would draw off what little moisture remains and harden the slough further. Option d is incorrect because dry gauze adds no moisture at all and leaves the slough exactly as it is. It also desiccates the surrounding bed, and epithelial cells cannot migrate across a surface that has dried out.

Correct Answer: Continuous feeding by pump over many hours

The jejunum has no reservoir capacity, so it cannot accept a volume delivered quickly. Post-pyloric feeding is given continuously by pump, which holds a steady rate and prevents the cramping, distension and dumping that rapid delivery causes. Option a is incorrect because bolus delivery depends on the stomach stretching to hold the volume. Pushing formula directly into the jejunum produces cramping, nausea and osmotic diarrhea, the picture known as dumping syndrome. Option b is incorrect because an intermittent schedule still delivers a set volume over a short window, which the small bowel cannot buffer. Gravity delivery suits a gastric tube in a client who tolerates it. Option c is incorrect because cyclic feeding exists to free a client for oral intake during the day. Nothing here suggests this client is eating, and the overnight run would still be a pump infusion.

Correct Answer: Healing by tertiary intention

A contaminated wound left open, packed, and then surgically closed after several days heals by tertiary intention. The delay lets the surgical team control bacterial load and edema before the edges are approximated, lowering the risk of breakdown. Option a is incorrect because primary intention requires edges approximated at the time of the original operation, as with a sutured clean incision. This wound stayed open for days, so it cannot be described that way. Option b is incorrect because an open packed wound is only half the picture. Secondary intention means no surgical closure is ever planned and the defect fills with granulation on its own, which is not what the surgeon intends here. Option d is incorrect because regeneration replaces lost tissue with tissue identical to it, and only the epidermis manages that. This abdominal wound has lost dermis and deeper layers, so it will close with granulation and scar.

Correct Answer: A wet gurgly voice after each sip

A wet or gurgly voice after swallowing means liquid is resting on the vocal cords, so material is entering the airway rather than the esophagus. The nurse stops the meal and reports this finding. Option b is incorrect because temperature preference is a matter of taste and comfort. Some clients with a weak swallow do notice cold or carbonated fluids more easily, but liking warm food signals nothing unsafe. Option c is incorrect because asking for more food is reassuring. Clients with dysphagia usually eat less, take a long time over a meal and avoid textures that frighten them, so appetite here is a favorable sign. Option d is incorrect because dry mouth is common after stroke and from many medications and does worsen swallowing, yet it is not itself a sign of unsafe swallowing. Tolerating a sip without coughing never rules out silent aspiration.

Correct Answer: Passage of flatus with a soft abdomen

Advancing a postoperative diet requires evidence that the gut has resumed working. Passing flatus, a soft nondistended abdomen and the absence of nausea or vomiting together show the client is tolerating what is already ordered. Option a is incorrect because a normal temperature speaks to infection rather than to bowel function. A client can be afebrile and still have an ileus, and feeding into an ileus produces distension and vomiting. Option c is incorrect because albumin changes over weeks and drops with the inflammation of surgery itself. Waiting on that value would stall the diet for far longer than recovery of the bowel actually takes. Option d is incorrect because incisional comfort is managed with analgesia and tells the nurse nothing about motility. Many clients are comfortable at rest while the bowel remains quiet, and the diet must not advance on that basis.

Correct Answer: A carton of vanilla ice cream

Ice cream is liquid at room temperature but is not transparent, which places it on the full liquid list. A clear liquid diet allows only fluids that can be seen through at body temperature. Option a is incorrect because clear broth is a standard component of this diet. It is transparent, leaves no residue in the bowel and supplies sodium and a little fluid to a client just off nothing by mouth. Option b is incorrect because plain gelatin without fruit pieces qualifies as a clear liquid. Lemon is also an acceptable color, since only red and purple items are avoided when a colonoscopy is planned. Option d is incorrect because strained apple juice contains no pulp and remains see through, so it belongs on the tray. Cranberry and white grape juice are permitted for the same reason.

Correct Answer: Stop the meal and remove food

Stopping the feeding is the first action because it prevents any further material from reaching a compromised airway. The client stays upright, the forceful cough is encouraged, and assessment of oxygenation and breath sounds follows. Option a is incorrect because a forceful cough clears an airway better than any catheter can. Suctioning a client who is coughing effectively can trigger gagging and vomiting, and it is reserved for a weak or absent cough. Option b is incorrect because notification follows the nursing actions that protect the airway. The provider will need a report once the client is stable, but calling first leaves food in front of a client who is aspirating. Option c is incorrect because lying the client back removes the gravity that is helping keep the bolus out of the trachea. Upright or side lying positioning is what protects the airway during and after an episode.

Correct Answer: Albumin drops with inflammation, not just malnutrition

Albumin is a negative acute phase protein whose level falls with inflammation, infection and liver disease regardless of intake. In sepsis a low value reports the inflammatory response, not the client's nutritional state. Option b is incorrect because albumin turns over slowly, with a half life of about three weeks. Prealbumin moves in roughly two days and is the faster of the pair, yet neither shifts within hours. Option c is incorrect because feeding does not correct the value while the inflammatory process continues. The level tends to recover when the sepsis resolves, which is why it cannot be used to judge whether feeding is working. Option d is incorrect because national consensus criteria deliberately left albumin and prealbumin out of the defining characteristics for malnutrition. Weight loss, poor intake, muscle and fat wasting, fluid accumulation and grip strength replaced them.