2. List four examples of a primary skin lesion including description and example of

NCLEX Blitz Post Assignment

• List the pertinent information that should be included in a transfer report.

➢ Nurse needs to confirm facility is ready for patient transfer as well as mode of transfer and time. Transfer documentation includes diagnosis, demographic information, health status, plan of care, vital signs, medications, PRN meds, allergies, active orders, equipment patient needs/uses, code status, family involvement.

• List four (4) examples of a primary skin lesion including description and example of

each.

➢ Macule: nonpalpable, smaller than 1cm looks like a freckle or petechiae

➢ Papule: solid elevation of the skin like nevus, smaller than 1cm

➢ Nodule: palpable, deep, firm, 1-2cm looks like a wart

➢ Vesicle: serous fluid filled, smaller than 1cm, blister, herpes simplex, varicella

• Provide an example of appropriate documentation of the integumentary system

➢ The patient’s skin is warm to touch with tenting noted. Appropriate skin color for ethnicity/pink skin. Capillary refill should be less than 3 seconds. Even hair distribution. Dry skin. Note pulses and edema if present.

• A nurse is providing discharge education to a client regarding home wound care. What

manifestations of wound infection should the nurse include in this education?➢ Identify if bleeding, apply pressure. Stabilize the wound do not pick at it. Patient should follow up with provider, notify provider of infection, drainage, redness around the wound, pus, swelling, tenderness, fever.

• A client has been diagnosed with Varicella. What type of tier transmission precaution is

required? What protective equipment will be required for prevention of transmission?➢ Airborne “My Chicken Hez TB” ➢ Private room with masks for caregivers/visitors ➢ Negative pressure airflow

• Describe the Tier 2 precautions to implement in the client with suspected Meningitis

➢ (droplet precautions) ➢ Private room ➢ Masks

• List at least five (5) priority considerations when performing a sterile dressing change.

➢ Initial step is to wash hands to prepare ➢ Sterile field can only touch sterile items ➢ Place field on surface before opening gloves. Open from the corners ➢ Keep sterile field above waist level ➢ Do not reach over sterile items because microbes have the ability to move/travel

• Identify three (3) priority teaching points to include when educating a client to use a cane.

➢ C.O.A.L. → Use cane on the good side or opposite of affected leg ➢ Advance cane simultaneously with affected leg ➢ The unaffected leg should bear weight first

• A nurse is caring for a client receiving oxygen therapy. What is the expected reference

range when obtaining oxygen saturation level? Identify four (4) reasons the reference range may be lower.

➢ 95-100%

➢ COPD, Asthma, pulmonary edema, emphysema

• Describe tertiary prevention measures and provide one (1) example.

➢ The goal is to prevent long term problems from the current illness ➢ An alcoholic going to Alcoholics Anonymous, a support group.

• List five (5) expected assessment findings for the older adult due to the physical changes

during aging.➢ Dry skin ➢ Shortening of the spine ➢ Reduced muscle mass ➢ Limited ROM ➢ Slower reaction

• A nurse is caring for an elderly client with constipation. What are three (3) complications

to monitor for during care of this client?➢ Straining from fecal impaction ➢ Hemorrhoids ➢ Hypotension

• How should the nurse respond when the client requests information about meditation?

➢ Meditation can be self-practiced to help calm the body and is a form of nonpharmacological measure in attempt to focus on breathing

• The nurse is caring for a client who has been diagnosed as hypovolemic and has been

ordered fluid replacement therapy. What lab values would indicate hypovolemia due to dehydration and why?➢ Increase in Hct, specific gravity, sodium, and serum osmolarity because the body is losing water and urine which makes the urine more concentrated.

• The physician prescribes meperidine 25 mg IM now for a client's pain. Available:

Meperidine 100 mg/mL How much meperidine will the nurse administer?

16.➢ 25/100 = 0.4 mg (desired/available)

• What action should a nurse implement to prevent clogging of the NG tube after

medication administration?➢ Flush the tubing before and after administration

• Identify three (3) manifestations of late hypoxemia.

➢ Confusion ➢ Cyanotic skin ➢ bradycardia

• What may an elderly client complain of when experiencing decreased cardiac output and

decreased contraction strength?➢ Restlessness ➢ Fatigue ➢ Cold clammy skin

• What questions should a nurse ask when obtaining a health history for a client with a

history of chest pain and dyspnea?➢ When does the chest pain start, what precipitates it, what makes it worse, is it relieved by nitroglycerin or rest?

• A client’s lab values indicate a serum sodium level of 150 mEq/L. How could this affect

the client’s vital signs?➢ Elevated serum sodium level could lead to cardiac dysrhythmias which indicates hypernatremia and can also neuro and endocrine problems.

• A nurse is caring for a client with pneumonia that is experiencing dyspnea. How should

the nurse position this client and why?➢ High fowlers to facilitate oxygen to the lungs