Question

A nurse is providing an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

Answer 1

Correct Answers:

Deep vein thrombosis

Rationale :

🔹 A hospital-acquired injury (HAI) refers to a condition or complication that develops during hospitalization and was not present on admission.

🔹 Deep vein thrombosis (DVT) is a prime example—it may occur due to immobility, surgery, or inadequate prophylaxis while hospitalized.

🔹 Diabetes mellitus, hypertension, and hypothyroidism are chronic diseases, not caused by hospitalization, so they are not classified as hospital-acquired injuries.

🔹 Including DVT in staff education highlights the need for preventive measures such as early ambulation, SCDs, anticoagulants, and hydration.

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Answer 2

Correct Answers:

Remove the protective gowh before leaving the client's room.

Rationale :

🟢 Clients with Clostridium difficile (C. diff) require contact precautions to prevent spore transmission.

🟢 The protective gown must be removed inside the client’s room before exiting to prevent carrying organisms into the hallway.

🟢 Gloves are removed before the gown to minimize contamination when doffing PPE.

🟢 Bed linens should never be shaken, as this disperses spores into the air.

🟢 An electronic thermometer should not be shared among patients with C. diff; a dedicated disposable thermometer is recommended.

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Answer 3

Correct Answers:

General anesthesia

Rationale :

🔷 General anesthesia causes complete loss of consciousness, absence of sensation, and lack of arousability, even with painful stimuli. It requires airway support and continuous monitoring of vital signs.

🔷 Regional anesthesia (likely meant as "spinal/epidural") numbs a specific region but the client remains awake and can respond.

🔷 Moderate sedation (conscious sedation) depresses consciousness, but clients can still respond to verbal commands or light tactile stimulation.

🔷 Local anesthesia only numbs a small, targeted area while the client stays fully awake and alert.

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Answer 4

Correct Answers:

Unrelieved pressure over bony prominences.

Rationale :

🌟 The primary risk factor for pressure injury development is sustained, unrelieved pressure, especially over bony prominences such as the sacrum, heels, hips, and elbows.

🌟 Constant pressure reduces capillary blood flow, leading to ischemia, tissue damage, and skin breakdown.

🌟 Other factors (moisture, friction, shear, poor nutrition, immobility) contribute, but the root cause is unrelieved pressure.

🌟 Excessive physical activity, high protein intake, or frequent bathing do not independently cause pressure injuries, though poor skin care practices can worsen them.

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Answer 5

Correct Answers:

Check the client's gag reflex.

Rationale :

🔹 After surgery, clients are at risk for aspiration because anesthesia can temporarily suppress the gag and swallow reflexes.

🔹 Before offering anything by mouth, including ice chips, the nurse must ensure the gag reflex has returned to confirm the airway can be safely protected.

🔹 Lowering the head of the bed increases aspiration risk, not safety.

🔹 Checking for bladder distention is important in post-op assessment but unrelated to giving ice chips.

🔹 Removing a peripheral IV is inappropriate unless the provider discontinues it.

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Answer 6

Correct Answers:

3+

Rationale :

🔹 Pitting edema is graded on a scale from 1+ to 4+, based on the depth of the indentation and how long it persists.

🔹 1+ edema: 2 mm indentation, disappears quickly.

🔹 2+ edema: 4 mm indentation, lasts a few seconds.

🔹 3+ edema: 6–8 mm indentation, remains several seconds to a minute.

🔹 4+ edema: >8 mm indentation, lasts 2–5 minutes or longer, often with gross swelling.

🔹 An 8 mm indentation corresponds to 3+ edema, which is significant and indicates more advanced fluid retention.

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Answer 7

Correct Answers:

The condition of the client's skin.
The client's health literacy level.
The client's ability to sit.

Rationale :

🟢 The condition of the client’s skin

📌Assessing the skin is essential in a mobility assessment because clients with impaired mobility are at high risk for pressure injuries.

📌Limited repositioning, friction, and shear forces contribute to skin breakdown, especially over bony prominences such as the sacrum, heels, and elbows.

📌By observing for redness, warmth, tears, or breakdown, the nurse can implement preventive strategies such as turning schedules, pressure-relieving devices, and skin care routines.

📌Documenting the skin’s condition also provides a baseline for monitoring changes during hospitalization.

🟢 The client’s need for assistance with ADLs

📌Functional mobility is closely linked to a client’s ability to perform activities of daily living (ADLs), including bathing, dressing, eating, toileting, and grooming.

📌Assessing ADL needs helps determine whether the client requires full assistance, partial help, or independence, guiding staffing and discharge planning.

📌This evaluation also directs referrals to occupational or physical therapy to improve independence and reduce caregiver burden.

📌Collecting this data ensures that safety measures are in place, such as assistance with transfers or ambulation devices.

🟢 The client’s ability to sit

📌Sitting tolerance and stability are fundamental indicators of a client’s postural control and core strength.

📌The ability to sit upright demonstrates readiness for safe transfers, ambulation, and rehabilitation activities.

📌Clients unable to sit unsupported may be at high fall risk and require close supervision or assistive devices.

📌Assessing sitting balance provides information about neurological function, musculoskeletal strength, and rehabilitation potential, shaping the mobility care plan.

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Answer 8

Correct Answers:

To maintain proper body alignment and comfort

Rationale :

🟣 Repositioning an immobile older adult every 2 hours is vital to maintain proper body alignment, which reduces discomfort and prevents musculoskeletal strain.

🟣 It also relieves constant pressure on bony prominences, which is the primary method of preventing pressure injuries (bedsores).

🟣 Regular repositioning promotes better circulation, lung expansion, and skin integrity, lowering risks of complications such as pneumonia, contractures, and skin breakdown.

🟣 While repositioning may incidentally increase comfort or allow social contact, its main clinical purpose is protecting skin and musculoskeletal health in immobile clients.

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Answer 9

Correct Answers:

Hemoglobin

Rationale :

🔵 Hemoglobin, a protein found in red blood cells, is the primary transporter of oxygen in the blood. It binds oxygen molecules in the lungs and releases them to body tissues where oxygen is needed.

🔵 Each hemoglobin molecule can carry up to four oxygen molecules, making it essential for maintaining cellular oxygenation.

🔵 Neutrophils and lymphocytes are white blood cells involved in immune defense, not oxygen transport.

🔵 Platelets function in clotting, not in oxygen delivery.

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Answer 10

Correct Answers:

The client seems to be more comfortable performing self-administration of insulin.

Rationale :

🟢 Documentation in nursing must be objective, factual, and measurable—not based on vague impressions or assumptions.

🟢 The phrase “seems to be more comfortable” is subjective and reflects the nurse’s interpretation rather than observable evidence.

🟢 In contrast, noting that the client demonstrated proper technique, recording the factual FBS value, and charting the client’s exact verbal statement in quotes are examples of correct, objective documentation.

🟢 Revising subjective entries ensures accuracy in the medical record, which is crucial for communication, continuity of care, and legal protection.

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QLexNursing

1 :
A nurse is providing an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

2 :
A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

3 :
A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that the client is not arousable during which of the following types of anesthesia?

4 :
What is the main risk factor for the development of pressure injuries?

5 :
A nurse is caring for a client who is postoperative, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

6 :
A nurse is assessing a client for pitting edema and notes an indentation of 8 mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

7 :
A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select All that Apply.)

8 :
Why is it important to reposition an older adult client who is immobile every 2 hours?

9 :
A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood?

10 :
A charger nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

QLexNursing

1 : A nurse is providing an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

2 : A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

3 : A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that the client is not arousable during which of the following types of anesthesia?

4 : What is the main risk factor for the development of pressure injuries?

5 : A nurse is caring for a client who is postoperative, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

6 : A nurse is assessing a client for pitting edema and notes an indentation of 8 mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

7 : A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select All that Apply.)

8 : Why is it important to reposition an older adult client who is immobile every 2 hours?

9 : A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood?

10 : A charger nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

1 :
A nurse is providing an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

2 :
A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

3 :
A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that the client is not arousable during which of the following types of anesthesia?

4 :
What is the main risk factor for the development of pressure injuries?

5 :
A nurse is caring for a client who is postoperative, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take?

6 :
A nurse is assessing a client for pitting edema and notes an indentation of 8 mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

7 :
A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment? (Select All that Apply.)

8 :
Why is it important to reposition an older adult client who is immobile every 2 hours?

9 :
A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood?

10 :
A charger nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?