Comprehensive Nursing Exam 3 Practice Guide: Rationales and Mastery

NCLEX-Style Testing Strategies and Study Tips

• Effective Test-Taking Strategy: A recommended technique for NCLEX-style exams is to cover the answer choices, think of the answer independently, and even jot down notes on the test form before looking at the options. Often, the student already knows the answer before seeing the provided choices.
• Reading and Highlighting: A primary reason for poor performance on exams is failing to read the question correctly. Highlighting the main points of a question is essential to slow down the reading process and focus on what the question is specifically asking.
• Negative Stem Questions: When a question asks for the "wrong" action or what the nurse should "counsel" against, it is a negative stem. A helpful strategy is to label answer choices as True (Right thing to do) or False (Wrong thing to do) next to each option.

Nursing Delegation and Scope of Practice

• Unlicensed Assistive Personnel (UAP) Delegable Tasks: Tasks that are within the UAP scope of practice include:     - Providing personal hygiene (e.g., bathing).     - Assisting with eating breakfast.     - Assisting with toileting.     - Monitoring intake and output (I&O).     - Assisting with mobility and ambulation.     - Repositioning a patient using a trapeze.     - Reporting increased wound drainage to the RN.     - Observing changes in dietary intake.
• Non-Delegable Tasks for UAPs: The following requires the professional judgment of an RN and cannot be delegated:     - Interpretation of abnormal vital signs.     - Assessing the patient's skin during a bath (Assessment is the RN's responsibility).     - Assessing the patient's ability to perform range-of-motion (ROM) exercises.     - Teaching the patient how to walk with a cane.     - Notifying the health care provider (HCP) of changes in status (Reporting to the RN is allowed, but the RN communicates with the HCP).     - Assessing a wound (e.g., a chronic, nonsterile wound).
• Rules of Delegation:     - A UAP cannot "re-delegate" a task (e.g., giving vital sign duties to a student nurse). Delegation must come from the RN.     - If a UAP attempts to teach or assess, a nurse manager or preceptor must intervene.

Cultural Competence and Communication

• Culture vs. Ethnicity:     - Culture: Socially transmitted; involves patterns of behavior and beliefs within a group.     - Ethnicity: Identification with a specific group, often characterized by shared heritage, language, or common history. It is distinct from biological determination.
• Limited English Proficiency (LEP): The best action when working with a patient with limited English is to use a professional interpreter. While drawings, simple sentences, or family members may seem helpful, they do not replace the accuracy and legal requirement of a professional service.
• Cultural Assessment and Planning: When working with an unfamiliar culture, the nurse should assess the patient's cultural beliefs related to health care and then create a nursing plan of care tailored to that specific patient. Using a "standard" plan ignores individual cultural needs.
• Cultural Maintenance: This involves nursing actions that help the patient preserve relevant care values. An example is assisting a patient with a healing ritual that is significant to their culture.
• Interacting with Unfamiliar Cultures: In a home health setting, the nurse should be transparent and tell the family that they need to learn about their culture. This fosters a collaborative and respectful environment.

Mobility and Physical Exercise

• Postoperative Goals: For a patient one day post-op from a hip fracture with impaired mobility, an appropriate goal is: "Patient will ambulate to the bathroom with assistance."
• Isometric Exercises: These involve muscle contraction without changing the length of the muscle or moving the joint. A prime example is Kegel exercises. Other common forms of exercise like walking, running, or weightlifting (isotonics/isokinetics) involve joint movement.
• Mobility and Safety:     - Narcotics and Mobility: After medicating a patient with a narcotic, the nurse must be immediately aware of dizziness as a potential adverse effect before assisting with ambulation.     - Repositioning Steps: The first step in repositioning a patient in bed is to raise the bed to a working height to protect the nurse's back and ensure patient safety.
• Orthostatic Hypotension: This is a drop in blood pressure when changing positions. Patients should be taught to get up slowly and carefully to avoid dizziness and falls. They should avoid getting up quickly.

Wound Classification and Healing Intentions

• Closed Wounds: A large bruise (contusion) on the side of the face is classified as a closed wound because the skin surface remains intact while underlying tissue is damaged.
• Open Wounds: Examples include puncture wounds, abrasions, and sutured surgical incisions.
• Healing by Intentions:     - Tertiary Intention: Also known as delayed primary closure, this occurs when a wound is purposely left open initially (often due to contamination or edema) and is closed later with sutures once the issue is resolved.
• Signs of Infection: Common signs include redness, pus (purulent drainage), and warmth. While a wound "needs to be treated," this is a management step rather than a clinical sign or symptom.

Pressure Injury Management

• Pressure Injury Staging:     - Stage 3: Characterized by full-thickness skin loss. It does not extend through the fascia and does not typically involving the exposure of bone or connective tissue (which would be Stage 4). It may involve undermining or tunneling.
• Nursing Diagnoses and Goals:     - For Impaired Skin Integrity (Stage 3): "Wound will show signs of healing within 2 weeks."     - For Impaired Physical Mobility: "Patient will be able to assist with position changes using over-bed trapeze within 1 week."
• Skin Layers: The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and provides a cushioning effect.
• Repositioning for Pressure Prevention: To avoid putting a patient in a side-lying position at risk for pressure injuries, the head of the bed should be placed at $30$ degrees.

Wound Care Complications and Procedures

• Wound Dehiscence: Suspected when a patient complains of a "popping sensation" and wetness in the dressing post-abdominal surgery (the splitting open of a wound).
• Wound Evisceration: A medical emergency where internal organs protrude through a dehisced wound. The priority nursing action is to cover the wound with gauze soaked with sterile normal saline to prevent the tissue from drying out and notify the surgeon immediately.
• Debridement Types:     - Mechanical Debridement: Includes wet-to-dry dressings, whirlpool baths, and wet-to-damp dressings.     - Enzymatic Debridement: Uses chemical agents (enzymes) to break down necrotic tissue; it is not a mechanical form.
• Dressings:     - Occlusive Dressings: Used for autolytic debridement (using the body's own enzymes) and should not be used on infected wounds. Hydrocolloids are a type of occlusive dressing.     - Hydrocolloid Dressings: Appropriate for wounds with a moderate amount of drainage.
• Drains:     - Penrose Drain: A gravity drain that is typically not sutured in place; care must be taken not to dislodge it during dressing changes.
• Irrigation and Thermal Therapy:     - After wound irrigation, the skin should be dried to prevent skin breakdown from excess moisture.     - If a patient complains of severe pain during a dressing change, the nurse must stop the procedure immediately.     - Heat/Cold Safety: Aqua-K pads require distilled water. Microwaving a hot pack is unsafe as it leads to uneven heating and potential burns. Ice bags should be filled $2/3$ full.

Cognitive and Sensory Alterations

• Delirium: A state of confusion that is often reversible and can be caused by sensory overload. It is not classified as a mood disorder.
• Hearing Assessment: The correct procedure involves whispering to the patient while standing on each side to check for auditory acuity.
• Peripheral Neuropathy: Patients must be taught not to go barefoot (even in summer) and avoid soaking feet in hot tubs or using ice packs due to reduced sensation and risk of injury.
• Confusion Goals: An appropriate goal for acute confusion is: "The patient will respond appropriately to questions about place within $48$ hours."
• Social Isolation: Goals include having the patient interact with other residents during activities.
• Safety in Cognitive Alterations: Home safety includes keeping the home free of dangerous objects (scissors), minimizing visitors to reduce overstimulation, and utilizing $24$-hour supervision.
• Sensory Overload: Environmental management includes keeping noise levels low and scheduling care activities together to allow for rest periods. Keeping the room "well lit" may actually increase overload.
• Visual Alterations: To ensure safety for patients with visual impairments, passageways should be wide and throw rugs removed. Lighting should be bright, not dim, to maximize remaining vision.

Stress, Anxiety, and Psychosocial Nursing

• Physiological Responses: The "Fight or Flight" response (sympathoadrenal response) involves racing heart and nausea due to hormone release during stressful events or procedures.
• Anxiety Levels:     - Mild Anxiety: Can actually improve memory, creativity, and alertness.     - Moderate Anxiety: Characterized by a narrowed focus of perception, not an increased perception.
• Stress Assessment: A culturally sensitive way to assess stress impact is to ask: "Do you have certain beliefs that are helpful during times of stress?"
• Physical Signs of Stress: Increased heart rate (e.g., $110\,\text{beats/min}$) is a cardinal sign of stress response.
• Coping Skills: The most useful question to assess coping is: "How have you managed stressful situations in the past?"
• Anxiety Goals: "The patient will report increased ability to concentrate on care instructions before discharge."

Postoperative and Respiratory Nursing Priorities

• Airway Preservation: If a post-op patient is snoring and pulse oximetry drops to $88\%$, the nurse must first assess the airway and administer oxygen.
• Postoperative Refusal to Move: If a patient refuses to ambulate due to pain, the nurse should explain the importance of movement to prevent complications like blood clots (DVT).
• Hemorrhage and Dehiscence: If a patient feels something "rip open" while walking and blood is visible, the nurse should assist the patient to the floor and call for help to prevent further injury or fainting.
• Surgical Safety: Once a patient is sedated for surgery, the priority is raising side rails to prevent falls.
• Respiratory Interventions:     - Spirometry: If breath sounds are shallow and diminished post-op, the nurse ensures the patient uses the incentive spirometer $10$ times every hour.     - Correct Spirometry Technique: The patient should inhale slowly so the marker rises, hold the breath for $3$ to $5$ seconds, and use it $5$ to $12$ times every $1$ to $2$ hours while awake. Breathing "into" the device is incorrect; they must inhale through it.
• Prioritization (Triage):     - Address a patient who has not voided for $8$ hours after catheter removal before addressing routine dressing changes or ambulation.     - In cardiopulmonary arrest, use a bag-valve-mask unit for oxygen delivery.     - Airway Priority: "Impaired airway clearance r/t thick secretions" is a higher priority than activity intolerance in pneumonia.
• Cardiovascular/Pulmonary Events: For a pulmonary embolism (PE), the highest priority goal is maintaining pulse oximetry values of at least $95\%$ on room air.
• COPD Assessment: If a COPD patient becomes confused and disoriented, this may indicate hypoxia or hypercapnia, requiring immediate assessment.