NUR101: Chapter NCLEX QUESTIONS (final review)

Chapter 16 (study guide) Performing a culture and sensitivity test when a patient has a wound infection is important because: A.) Antibiotics will kill the bacteria. B.) Different organisms are killed by specific antibiotics. C.) Some wound infections should not be treated. D.) Cleansing alone will not cure the infection.

B [Different organisms are killed by specific antibiotics.]

Chapter 20 (study guide) When utilizing a safety belt for a patient in a wheelchair, you must: A.) Explain to the family exactly why it is being used.) B.) Document the specific reason the belt is needed. C.) Fasten it to the chair loosely. D.) Obtain the patient's permission for use.

B [Document the specific reason the belt is needed.]

Chapter 18 (text book) You have assisted your patient to the prone position. Which intervention is most important. A.) Ask if he has any neck discomfort. B.) Count his respirations. C.) Offer him a magazine. D.) Place the call bell within reach.

B [Count his respirations]

Chapter 20 (study guide) A new Joint Commission Patient Safety Goal concerns: A.) Injuries to health care workers. B.) Use of anticoagulant medications. C.) Temperature of served liquids at meals. D.) Equipment electrical safeguards.

B [Use of anticoagulant medications.]

Chapter 20 (study guide) The best choice for a protective device to assist a patient who cannot maintain an upright sitting posture in a wheelchair would be: A.) a security vest. B.) a safety belt. C.) a protective jacket. D.) wrist immobilizing devices.

B [a safety belt.]

Chapter 16 (website) An example of naturally acquired passive immunity is: A.) influenza vaccine. B.) breast milk. C.) tetanus antitoxin. D.) polio vaccine.

B [breast milk.]

Chapter 20 (study guide) The first action to be taken in the event of a fire is to: A.) activate the fire alarm. B.) rescue the patient. C.) contain the fire. D.) extinguish the flames.

B [rescue the patient.]

Chapter 19 (text book) Your patient has an area at the left trochanter that is reddened with slightly abraded skin. You would stage this as a _______ pressure ulcer. A.) stage I B.) stage II C.) stage III D.) unstageable

B [stage II]

Chapter 16 (study guide) Considering the chain of infection and the way pathogens are transmitted, which of the following is considered a reservoir? A.) Contaminated water B.) Mosquito C.) Contaminated metal instrument D.) Contaminated dressings

A [Contaminated water]

Chapter 17 (study guide) When changing the bed of an incontinent patient, you should wear both gloves and a gown because: A.) Contamination of the uniform is likely. B.) Feces stains are hard to remove. C.) The uniform will carry an odor after this task. D.) Urine will soak through the uniform to the skin.

A [Contamination of the uniform is likely.]

Chapter 16 (study guide) The redness and warmth in an inflamed area is due to: A.) Dilation of blood vessels and increased blood flow. B.) Increased temperature in the affected tissues. C.) Phagocytosis and chemical action against pathogens. D.) Formation of debris, causing tissue swelling.

A [Dilation of blood vessels and increased blood flow.]

Chapter 17 (text book) Standard precautions are used: A.) For all patients. B.) For all patients unless they are under Transmission-Based Precautions. C.) For all patient's except those in protective environment isolation. D.) For any patient the nurse believes might be infectious.

A [For all patients]

Chapter 20 (study guide) Medications may have side effects that contribute to the risk of falls, especially for older adults. When evaluating a patient's drugs for side effects that may increase the risk of falling, look at those that affect the ______________ system. (fill in the blank)

cardiovascular

Chapter 16 (study guide) Various types of organisms cause different disorders. Vaginal Candidiasis is caused by ________________. (fill in the blank)

fungi

Chapter 20 (text book) Terrorist attacks can occur from release of biologic or chemical agents or radiation. Bioterrorism is the release of ____________ into a community to achieve political and/or military goals. (fill in the blank)

pathogenic organisms

Chapter 16 (study guide) Another body defense occurs in the gastrointestinal system as the: A.) Hydrochloric acid in the stomach destroys pathogens. B.) Bile in the stool kills bacteria. C.) Digestive enzymes in the small intestine kills bacteria. D.) Peristaltic action of the intestines eliminates pathogens.

A [Hydrochloric acid in the stomach destroys pathogens.]

Chapter 20 (text book) Which of the following would help prevent the most frequent cause of injury tot he elderly patient? A.) Keeping pathways clear of papers and objects. B.) Grounding all electrical apparatuses in use. C.)Checking temperature of fluids before serving them. D.) Reviewing the dose and frequency of all ordered medications with the patient.

A [Keeping pathways clear of papers and objects]

Chapter 19 (study guide) Because of a pressure area, it would best to position the patient with a reddened, slightly abraded area on the inner aspect of her right knee: A.) On her back or right side. B.) On her back or left side. C.) Supine in semi-Fowler's only. D.) In Sims' position or supine.

A [On her back or right side.]

Chapter 16 (website) Which is an example of a helminth? A.) Pinworm B.) Mold C.) Lice D.) Yeast

A [Pinworm]

Chapter 19 (text book) Special attention is given to skin over bony prominences because: A.) Pressure ulcers are more likely to develop in these areas. B.) Pressure ulcers develop ONLY in these areas. C.) These areas are often dirtier. D.) The skin here tends to hold moisture.

A [Pressure ulcers are more likely to develop in these areas.]

Chapter 16 (study guide) Before sterilizing instruments, you should: A.) Rinse off all visible matter with cool water. B.) Soak them in cool water. C.) Soak them in alcohol. D.) Soak them in hot water.

A [Rinse off all visible matter with cool water.]

Chapter 17 (study guide) When in the operating room, you observe a surgical assistant contaminate her glove. You would: A.) State that the assistant's glove had become contaminated. B.) Tell your instructor what you observed after the surgery. C.) Check with the circulating nurse on what to do. D.) Ignore the instance and keep quite.

A [State that the assistant's glove had become contaminated.]

Chapter 19 (study guide) Your patient has an area of localized intact skin, maroon in color, that she describes as painful. You palpate the area and find it to feel "mushy" and warmer than the adjacent skin. You would document this as: A.) Suspected deep tissue injury. B.) Stage I. C.) Stage II. D.) An unstageable pressure ulcer.

A [Suspected deep tissue injury.]

Chapter 18 (text book) Forgetting to reposition a patient in a wheelchair for more than 1 hour may lead to: A.) The beginning of a pressure ulcer. B.) Muscle atrophy. C.) Pooling of lung secretions. D.) Skin abrasions from shearing forces.

A [The beginning of a pressure ulcer.]

Chapter 16 (study guide) Alcohol-based hand rubs are appropriate for hand hygiene because: A.) They are more effective than handwashing for ridding the hands of microorganisms. B.) They are a effective as handwashing, and are more convenient and cost-effective. C.) They are the most effective way to rid the hands of Clostridium difficile. D.) They are the most effective way to rid the hands of tuberculosis spore-forming microorganisms.

A [They are more effective than handwashing for ridding the hands of microorganisms.]

Chapter 18 (study guide) You are going to walk the stroke patient in his room for the first time with the assistance of another nurse. Which of the following will you do? A.) Use a gait belt and walk on his weaker side. B.) Provide support by having one nurse walk in front of the patient and the other behind him. C.) Hold him at the waist, walk backwards in front of him with the other nurse at his side. D.) Each support one arm and match his steps.

A [Use a gait belt and walk on his weaker side.]

Chapter 16 (website) Povidone-iodine is a type of: A.) antiseptic. B.) disinfectant. C.) cleanser. D.) antiinfective.

A [antiseptic]

Chapter 16 (website) To prevent urinary tract infection in an elderly client, a nurse should: A.) encourage intake of sufficient fluid to keep urine dilute. B.) encourage beverages with caffeine. C.) encourage no more fluids during the evening hours. D.) encourage tub baths.

A [encourage intake of sufficient fluid to keep urine dilute.]

Chapter 20 (study guide) The evidence demonstrates that using bed rails as a restraint can be: A.) harmful. B.) harmless. C.) effective. D.) useless.

A [harmful.]

Chapter 20 (study guide) The main cause of noise in the hospital is: A.) people talking. B.) equipment and alarm sounds. C.) meal delivery carts. D.) footsteps of all the workers.

A [people talking.]

Chapter 18 (text book) When moving the patient up in bed: A.) place one foot in front of the other. B.) use only those muscles absolutely necessary. C.) pushing is better than pulling. D.) lock the knees before moving the patient.

A [place one foot in front of the other.]

Chapter 16 (website) Recommended hand hygiene in health care settings includes: A.) use alcohol-based hand rub after removing gloves. B.) use soap and water only if hands are visibly soiled. C.) substitute antimicrobial-impregnated wipes. D.) Use antiseptic agents against spore-forming organisms.

A [use alcohol-based hand rub after removing gloves.]

Chapter 16 (text book) Before entering the room of a patient in Airborne Infection Isolation and Contact Precautions, the nurse must done a cover gown, gloves, mask, and eyewear. Indicate the proper sequence for donning the PPEs: ______, ______, _____, and ______. A.) Gown B.) Gloves C.) Mask D.) Eyewear

A, C, D, B [Gown, Mask, Eyewear, Gloves]

Chapter 18 (text book) An elderly person may need to be reeducated on how to lift safely because: (select all that apply) A.) Muscle and bone lose strength as one ages. B.) Bone density is decreased. C.) Muscle mass is decreased and posture changed. D.) She has forgotten how to lift things.

A, B, C [Muscle and bone lose strength as one ages.] [Bone density is decreased.] [Muscle mass is decreased and posture changed.]

Chapter 17 (text book) When making up the bed in an isolation room, the nurse: (select all that apply) A.) Places and unfolds linens carefully. B.) Wears gloves and a cover gown. C.) Checks on items the patient might need before entering the room. D.) Places dirty linens on the floor until finished.

A, B, C [Places and unfolds linens carefully.] [Wears gloves and a cover gown.] [Checks on items the patient might need before entering the room.]

Chapter 16 (website) Which is a multidrug-resistant organism? (select all that apply) A.) Methicillin-Resistant Staphylococcus Aureus (MRSA) B.) Extended-Spectrum Beta-Lactamase-producing (ESBL) gonorrhea C.) Clostridium difficile (C. diff) D.) Vancomycin-Resistant Enterococcus (VRE) E.) Influenza

A, B, C, D [Methicillin-Resistant Staphylococcus Aureus (MRSA)] [Extended-Spectrum Beta-Lactamase-producing (ESBL) gonorrhea] [Clostridium difficile (C. diff)] [Vancomycin-Resistant Enterococcus (VRE)]

Chapter 17 (study guide) When it is discovered that a hospitalized patient has developed an infection, which of the following take place? (select all that apply) A.) The patient is placed in a private room immediately. B.) A report is sent to the infection preventionist. C.) A culture is performed to determine the causative organism. D.) The infection preventionist investigates, looking for possible causes. E.) Appropriate prevention-based precautions are instituted.

A, B, C, D, E [The patient is placed in a private room immediately.] [A report is sent to the infection preventionist.] [A culture is performed to determine the causative organism.] [The infection preventionist investigates, looking for possible causes.] [Appropriate prevention-based precautions are instituted.]

Chapter 17 (text book) Which steps are to be taken when preparing a sputum specimen to go to the laboratory? (select all that apply) A.) Label the container. B.) Collect the specimen and secure the lid. C.) Place the container in a sealed plastic bag marked "biohazard". D.) Place the biohazard bag in another plastic bag. E.) Place the completed laboratory slip in the pocket on the bag. F.) Put the container in the rack for the laboratory courier.

A, B, C, E [Label the container.] [Collect the specimen and secure the lid.] [Place the container in a sealed plastic bag marked "biohazard".] [Place the completed laboratory slip in the pocket on the bag.]

Chapter 17 (text book) When performing a sterile dressing change on a patient, correct technique must be regarded as broken if: (select all that apply) A.) supplies are placed touching the edges of the sterile field. B.) a gloved hand touches the dressing table below the tabletop surface. C.) a sterile glove touches one of the sterile dressings on the field before the procedure begins. D.) the nurse reaches over the sterile field when placing a swab used to clean the wound in the discard bag.

A, B, D [supplies are placed touching the edges of the sterile field.] [a gloved hand touches the dressing table below the tabletop surface.] [the nurse reaches over the sterile field when placing a swab used to clean the wound in the discard bag.]

Chapter 17 (study guide) When working with a sterile field, you should: (select all that apply) A.) Always face the sterile field. B.) Keep the hands above the waist. C.) Use only one hand within the field. D.) Open sterile packages away from the body.

A, B, D [Always face the sterile field.] [Keep the hands above the waist.] [Open sterile packages away from the body.]

Chapter 17 (study guide) You are assigned to the operating room to assist with a minor surgical procedure. When performing the surgical scrub with soap and water, you do which of the following? (select all that apply) A.) Use continually running water. B.) Use an antiseptic agent and a scrub brush or pad. C.) Scrub to an inch above the elbow. D.) Scrub to 2 inches above the elbow.

A, B, D [Use continually running water.] [Use an antiseptic agent and a scrub brush or pad.] [Scrub to 2 inches above the elbow.]

Chapter 16 (study guide) Nurses pay great attention to skin care for patients because : (select all that apply) A.) Cleanliness reduces the chance of infection. B.) Dirty skin predisposes to skin breakdown. C.) Everyone should have a bath every day. D.) The skin is the first line of defense against infection. E.) Cleansing removes dead skin cells.

A, B, D, E [Cleanliness reduces the chance of infection.] [Dirty skin predisposes to skin breakdown.] [The skin is the first line of defense against infection.] [Cleansing removes dead skin cells.]

Chapter 20 (study guide) In order to prevent falls by older patients, you should: (select all that apply) A.) Encourage the use of noskid mats in tubs or showers. B.) Insist on bright lighting at all times. C.) Encourage the use of firm, rubber-soled slippers. D.) Keep side rails up when the patient is in bed.

A, C [Encourage the use of noskid mats in tubs or showers.] [Encourage the use of firm, rubber-soled slippers.]

Chapter 20 (study guide) Interventions by the nurse to help prevent patient falls are to: (select all that apply) A.) provide night lighting for trips to the bathroom. B.) allow the patients to walk only with assistance. C.) keep pathways between the bed and bathroom clear. D.) allow minimal patient belongings in the room.

A, C [provide night lighting for trips to the bathroom.] [keep pathways between the bed and bathroom clear.]

Chapter 19 (text book) Prevention of pressure ulcers is promoted by: (select all that apply) A.) Changing the patient's position every 2 hours. B.) Directly massaging reddened areas. C.) Keeping the heels of the immobile patient off the bed. D.) Using lift devices such as a trapeze bar to move patients.

A, C, D [Changing the patient's position every 2 hours.] [Keeping the heels of the immobile patient off the bed.] [Using lift devices such as a trapeze bar to move patients.]

Chapter 19 (study guide) When turning the patient, you provide skin care by: (select all that apply) A.) Assessing now-visible portions of the skin. B.) Providing a back massage after turning. C.) Rubbing all areas that were against the mattress. D.) Checking all bony prominences that were dependent for reddening.

A, D [Assessing now-visible portions of the skin.] [Checking all bony prominences that were dependent for reddening.]

Chapter 17 (text book) The nurse is preparing to assist a patient with his bath. He has an infected, draining wound. What PPE would be required for these tasks? (select all that apply) A.) Gown B.) Mask C.) Eyewear D.) Gloves

A, D [Gown] [Gloves]

Chapter 20 (study guide) Safety measures for the patient during ambulation include the use of: (select all that apply) A.) a gait belt any time the patient is unsteady. B.) two people at all times for ambulation. C.) a rolling IV pole for stability. D.) wearing of firm-soled shoes.

A, D [a gait belt any time the patient is unsteady.] [wearing of firm-soled shoes.]

Chapter 16 (text book) Drug resistant microorganisms are a problem within the community as well as within the hospital. Reasons for this include: (select all that apply) A.) Overprescription of antimicrobial agents by health care providers. B.) Lack of proper sanitation within communities. C.) Discharging patients with infected wounds before treatment is complete. D.) Patient's who stop taking antimicrobial agents as prescribed. E.)Overuse of inappropriate antimicrobials causing mutations in the microorganisms.

A, D, E [Overprescription of antimicrobial agents by health care providers.] [Patient's who stop taking antimicrobial agents as prescribed.] [Overuse of inappropriate antimicrobials causing mutations in the microorganisms.]

Chapter 16 (website) _______ is the practice of making the environment and objects free of microorganisms.

Asepsis

Chapter 16 (study guide) In what order would you put on the following personal protective equipment needed to care for your patient? 1.) Gloves 2.) Mask 3.) Gown 4.) Goggles/face shield A.) 3, 4, 1, 2 B.) 3, 2, 4, 1 C.) 2, 4, 3, 1 D.) 2, 3, 4, 1

B [3, 2, 4, 1]

Chapter 19 (text book) Which patient is at greatest risk for developing a pressure ulcer? A.) A 40-year-old paraplegic man who is obese and uses a self-propelling wheelchair. B.) An 80-year-old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence. C.) A 55-year-old man who had surgery this afternoon and is difficult to arouse. D.) A 75-year-old woman who is postoperative day 2 for hip replacement surgery.

B [An 80-year-old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence.]

Chapter 18 (text book) When performing passive range-of-motion exercises: A.) Help patients who are independently performing these activities. B.) Avoid moving the joint to the point of discomfort. C.) Perform each exercise at least 15-10 times. D.) Support the extremity above and below the joint.

B [Avoid moving the joint to the point of discomfort.]

Chapter 18 (study guide) Before transferring a stroke patient from the bed to a wheelchair, the most important step is to: A.) Position the chair so you can pivot him into it. B.) Engage the locks on the wheelchair. C.) Assist him with putting on his robe and slippers D.) Raise the head of the bed to Fowler's position.

B [Engage the locks on the wheelchair.]

Chapter 20 (text book) If a biohazard spill occurs in the dirty utility room on your unit and you are unfamiliar with the product involved, you would first: A.) Dilute the spill with water. B.) Find the MSDS. C.) Don gloves. D.) Call a housekeeper.

B [Find the MSDS]

Chapter 16 (study guide) Handwashing after removing gloves is necessary because: A.) Powder from the gloves remains on the hands. B.) Gloves are not 100% protective. C.) Contamination occurs when removing gloves. D.) Otherwise the gloves irritate the hands.

B [Gloves are not 100% protective]

Chapter 19 (study guide) When washing a patient's arm, you use long, firm strokes, moving from the hand to the axilla to: A.) Fully assess the skin on the side of the arm. B.) Improve circulation in the extremity. C.) Prevent infection by cleansing from dirty to clean. D.) Provide range-of-motion exercise for the joint.

B [Improve circulation in the extremity.]

Chapter 16 (text book) Malnutrition contributes to the susceptibility to infection because: A.) There is little energy for healing. B.) It decreases immune function. C.) It prevents sufficient exercise. D.) It upsets homeostatic balance in the body.

B [It decreased immune function]

Chapter 18 (text book) The oblique side-lying (lateral) position is helpful because: A.) The patient does not need to be repositioned as often. B.) It takes pressure off the trochanter and shoulder. C.) All areas of the lung will drain secretions to the bronchus. D.) The shoulder is rolled to a forward position.

B [It takes pressure off the trochanter and shoulder.]

Chapter 20 (study guide) Which of the following must be present on the nursing unit for each biohazard substance used or stored on the unit? A.) MDS B.) MSDS C.) DCP D.) DSS

B [MSDS]

Chapter 16 (text book) The reason for performing hand hygiene for 15-30 seconds when hands are contaminated is to: A.) Render the skin totally free of microorganisms. B.) Mechanically remove as many microorganisms as possible. C.) Increase the circulation in the hands. D.) Provide a thicker layer of soap foam.

B [Mechanically remove as many microorganisms as possible.]

Chapter 21 (text book) A newly admitted patient has a respiratory rate of 16 per minute. Which action should the nurse take? A.) Recount the respirations in 5 minutes. B.) Note the respiratory rate on the chart. C.) Check the chart for signs of a respiratory disorder. D.) Ask the patient to cough to clear the lungs.

B [Note the respiratory rate on the chart.]

Chapter 20 (study guide) Infection control guidelines for patient safety require that infectious waste such as soiled dressings be treated as biohazards and be: A.) Sterilized before disposal. B.) Placed in impermeable, sealed bags. C.) Burned as soon as possible. D.) Placed in the utility room trash.

B [Placed in impermeable, sealed bags.]

Chapter 21 (text book) Temperature greater than 105.8°F (41°C) should be treated promptly to reduce the fever because of: A.) Chemical reactions to oxygen in the bloodstream. B.) Potential damage to the cells of the central nervous system. C.) Heavy perspiration causing dehydration. D.) The increased workload of the heart.

B [Potential damage to the cells of the central nervous system.]

Chapter 19 (study guide) When washing a patient's face, you wash each eye area from the inner to the outer canthus with separate parts of the washcloth to: A.) Promote circulation. B.) Prevent infection. C.) Avoid getting soap in the eye. D.) Prevent visual obstruction.

B [Prevent infection]

Chapter 16 (study guide) Many gram-negative bacteria are more dangerous than gram-positive bacteria because they: A.) Multiply more rapidly. B.) Produce a dangerous endotoxin. C.) Cause severe diarrhea. D.) Are more virulent.

B [Produce a dangerous endotoxin.]

Chapter 18 (text book) When preparing to move a patient up in the bed who can assist, you would first: A.) Pull the bed covers down to the foot of the bed. B.) Raise the bed to a good working height. C.) Ask the patient to grab the upper guard rail. D.) Ask the patient to bend the knees and plant the feet on the mattress.

B [Raise the bed to a good working height.]

Chapter 20 (text book) The correct sequence of action in a fire is: A.) Call for help, activate the alarm, rescue a patient in danger, and extinguish the fire. B.) Rescue a patient in danger, activate the alarm, contain the fire, and extinguish the fire. C.) Call the hospital operator, race to close the fire doors, activate the alarm, and evacuate all patients. D.) Race to close the fire doors, activate the alarm, call the hospital operator, and evacuate all patients.

B [Rescue a patient in danger, activate the alarm, contain the fire, and extinguish the fire.]

Chapter 16 (study guide) Fever helps fight infection because heat: A.) Kills most pathogens. B.) Slows the growth of pathogens. C.) Causes diaphoresis and flushing out of bacteria. D.) Causes more water consumption and urine production.

B [Slows the growth of pathogens.]

Chapter 21 (text book) The person who makes harsh high sounds on inspiration has what kind of respiratory condition? A.) Bronchodilation B.) Stridor C.) Hyperventilation D.) Wheezing

B [Stridor]

Chapter 17 (study guide) When using a sterile surgical gown, you know that: A.) The entire gown is sterile unless you contaminate it, except for the waist tie. B.) The front of the gown is sterile from the shoulder to the table and 2 inches above the elbow. C.) The entire front of the gown is sterile including up to 2 inches below the elbows on the sleeves. D.) The front and back of the gown are sterile from the shoulder to table level.

B [The front of the gown is sterile from the shoulder to the table and 2 inches above the elbow.]

Chapter 17 (study guide) You know that a hospital-acquired infection often occurs because an opportunistic organism is more likely to cause infection when: A.) The patient's resistance is high. B.) The patient's resistance is low. C.) The home is dirtier than the hospital. D.) It is present in small numbers.

B [The patient's resistance is low.]

Chapter 18 (study guide) Considering the stroke patient's state of weakness, when planning to ambulate him it is important to: (select all that apply) A.) Ambulate after a meal when he is strongest. B.) Remember to plan the distance for a "round trip". C.) Use a gait belt for safety and stability. D.) Have someone follow with a wheelchair in case of weakness.

B, C [Remember to plan the distance for a "round trip".] [Use a gait belt for safety and stability.]

Chapter 16 (text book) The skin is the first line of defense and protects the body by: (select all that apply) A.) Repelling microorganisms. B.) Providing an intact physical barrier. C.) Secreting bactericidal substances. D.) Releasing macrophages. E.) Shedding dead cells.

B, C [Repelling microorganisms.] [Providing an intact physical barrier.]

Chapter 18 (study guide) Areas that should be checked for problems due to pressure when the patient has been in the supine position are: (select all that apply) A.) Hip and shoulder. B.) Scapula and sacrum. C.) Elbows and heels. D.) Hips and ankles.

B, C [Scapula and sacrum.] [Elbows and heels.]

Chapter 16 (study guide) Considering hand hygiene as a measure to prevent infection, important guidelines are that: (select all that apply) A.) A 5-minute scrub is always appropriate. B.) Handwashing time should be adjusted to the amount of contamination of the hands. C.) Hands should be washed with soap and running water to wash away microbes. D.) Only special antimicrobial soap will sufficiently kill microbes on the hands. E.) Alcohol rub must be applied to all hand surfaces.

B, C, E [Handwashing time should be adjusted to the amount of contamination of the hands.] [Hands should be washed with soap and running water to wash away microbes.] [Alcohol rub must be applied to all hand surfaces.]

Chapter 16 (study guide) Which of the following put the hospital patient at high risk for a health care-associated infection? (select all that apply) A.) Hospitalized more than 3 days. B.) Has open wound. C.) An indwelling Foley catheter. D.) Is eating little after surgery. E.) Has an intravenous line for IV fluids. F.) Has a surgical wound. G.) Is older than 50 years of age.

B, C, E, F [Has open wound.] [An indwelling Foley catheter.] [Has an intravenous line for IV fluids.] [Has a surgical wound.]

Chapter 20 (text book) In making a bed it is important to remember: (select all that apply) A.) To place soiled linens on the floor to avoid contaminating the bed. B.) To unfold linens on the bed to avoid stirring up air currents. C.) To return unused linens to the floor's clean linen area to prevent waste. D.) To raise the bed during the linen change to prevent back strain.

B, D [To unfold linens on the bed to avoid stirring up air currents.] [To raise the bed during the linen change to prevent back strain.]

Chapter 16 (text book) Means to decrease susceptibility of individuals to infection include: (select all that apply) A.) Discouraging visitors who have an infectious illness. B.) Using gloves and hand hygiene techniques properly. C.) Giving antibiotics prophylactically at the time of surgery. D.) Providing immunizations as available. E.) Promoting good nutrition and adequate rest.

B, D, E [Using gloves and hand hygiene techniques properly.] [Providing immunizations as available.] [Promoting good nutrition and adequate rest.]

Chapter 18 (study guide) A stroke patient's tray arrives with his lunch. As you feed him, you hand him a piece of bread, which he holds in his unaffected hand. As he moves his hand to his mouth to eat what movement does he use? A.) Flexion of the wrist. B.) External rotation of the shoulder. C.) Internal rotation of the shoulder. D.) Pronation of the wrist.

C [ Internal rotation of the shoulder.]

Chapter 20 (text book) Which of the following patients might be most likely to suffer a burn if left to tub bathe alone? A.) An adult female who is to have abdominal surgery tomorrow. B.) An adult male who has been having back pain after a cystoscopy. C.) A patient taking drugs that alter mental awareness. D.) An alert elderly patient who prefers tub bathing.

C [A patient taking drugs that alter mental awareness.]

Chapter 16 (text book) Considering the chain of infection, a vector might be: A.) An uninfected patient. B.) Staphylococcus bacteria. C.) A tick carrying Lyme disease. D.) A contaminated water supply.

C [A tick carrying Lyme disease]

Chapter 20 (study guide) When securing a protective device, it is essential that: A.) A double knot be used. B.) Only one finger can be inserted between the device and the patient. C.) An index and middle finger fits between the device and the patient. D.) It is tied securely to the side rails.

C [An index and middle finger fits between the device and the patient.]

Chapter 18 (text book) When a patient falls, you document in the nurse's notes: A.) Your best guess about what happened. B.) A statement concerning how you believe the hospital was negligent. C.) Any patient-stated cause of fall. D.) As little as possible to avoid liability.

C [Any patient-stated cause of fall.]

Chapter 18 (study guide) A 67-year-old male suffered a stroke 3 days ago. He has left arm and leg weakness (hemiparesis) and aphasia. His speech is limited to "boler", "soup", and "no". He is conscious and quite depressed. While preforming passive ROM to his affected extremities, he says, "boler, boler, boler." You don't understand what he is trying to say. What would you do now? A.) Report to the nurse that he is crying and might be having pain or discomfort. B.) Go ahead and carry out the bath and exercises, since he must be confused. C.) Ask the patient to nod his head for "yes" and shake his head for "no", then explain again and ask questions to see if he understands what you mean. D.) Tell him not to cry and reassure him that everything will be OK.

C [Ask the patient to nod his head for "yes" and shake his head for "no", then explain again and ask questions to see if he understands what you mean.]

Chapter 16 (study guide) Standard precautions were developed by the CDC to: A.) Protect patients B.) Protect health care workers C.) Break the chain of infection D.) Prevent hospital-acquired infections

C [Break the chain of infection]

Chapter 19 (study guide) The patient who has vascular insufficiency has toenails in need of trimming. You should: A.) Ask the family to bring nail clippers from home. B.) Ask her daughter to perform this function for her. C.) Call her podiatrist to come and trim them. D.) Seek an order from the physician to cut her toenails.

C [Call her podiatrist to come and trim them.]

Chapter 16 (study guide) Normally, the immune system does not attack the self because: A.) Only microorganisms cause antibody production. B.) Macrophages never attack one's own cells. C.) Cellular antigens help in distinguishing self from nonself. D.) Only foreign proteins cause antibody reactions.

C [Cellular antigens help in distinguishing self from nonself.]

Chapter 19 (text book) When providing foot care for a diabetic patient, you must remember to: A.) Cut the cuticles to avoid hangnails. B.) Never soak the feet. C.) Check for an order before trimming the nails straight across. D.) Check for an order before trimming the nails in a curved manner so there are not any sharp points to irritate the skin.

C [Check for an order before trimming the nails straight across.]

Chapter 20 (study guide) When utilizing a limb immobilizer protective device, you must: A.) Massage the area proximal to its attachment frequently. B.) Flex the joint before applying the device. C.) Check the circulation and sensation distal to the device frequently. D.) Exercise all joints at least twice per shift.

C [Check the circulation and sensation distal to the device frequently.]

Chapter 17 (study guide) When opening a sterile package, you should: A.) Open it toward your body. B.) Hold it down with one hand while opening it. C.) Drop the contents onto the sterile field without touching them. D.) Pull the package apart equally with each hand.

C [Drop the contents onto the sterile field without touching them.]

Chapter 18 (text book) You are dangling your patient in preparation for getting out of bed. Your plan is to dangle her for 2 minutes, then transfer her to the chair. After 1 minute she complains of nausea and states that she sees "stars". What should you do? A.) Reassure her that this will pass. B.) Get the BP cuff from across the room. C.) Gently lie her back down. D.) Wait 2 more minutes then check her BP.

C [Gently lie her back down.]

Chapter 19 (text book) The primary reason some hospitals prefer a bag bath to a traditional bath is: A.) Cost savings. B.) Time savings. C.) Infection control. D.) less mess.

C [Infection control]

Chapter 17 (study guide) For which of the following procedures would sterile technique be unnecessary? A.) Surgical wound dressing change. B.) Insertion of a Foley catheter. C.) Insertion of a nasogastric tube into the stomach D.) Changing a solution bag on an intravenous infusion.

C [Insertion of a nasogastric tube into the stomach]

Chapter 19 (study guide) The patient refuses perineal care. You know that this is probably because she: A.) Can do it well by herself. B.) Has no vaginal secretions and does not need it. C.) Is embarrassed to have someone else perform it D.) Prefers to do this only once a week.

C [Is embarrassed to have someone else perform it]

Chapter 19 (study guide) Which one of the following patients would need the most frequent attention to skin care and skin assessment? A.) Man who is paraplegic and uses a wheelchair during the day. B.) Older adult woman who is hospitalized with pneumonia. C.) Man who had a stroke, has right-sided hemiparesis, and is very groggy. D.) Woman who just had a laparotomy and appendectomy.

C [Man who had a stroke, has right-sided hemiparesis, and is very groggy.]

Chapter 17 (text book) The nurse is delivering a meal tray to a patient who is under droplet precautions for bacterial pneumonia. Which articles of personal protective equipment (PPE) need to be worn? A.) Gown, mask, gloves, shoe covers. B.) Special filtration mask and gloves. C.) Only a mask is needed. D.) No PPE required.

C [Only a mask is needed]

Chapter 17 (study guide) One of the difficult things to remember regarding Standard Precautions is to always: A.) Turn gloves inside out when removing them. B.) Instruct the patient when to use gloves. C.) Perform hand hygiene after removing gloves even when no contamination occurred. D.) Perform hand hygiene before gloving.

C [Perform hand hygiene after removing gloves even when no contamination occurred.]

Chapter 19 (study guide) When cleansing a patient's dentures, you would: A.) Soak them in vinegar before scrubbing. B.) Scrub them while in the denture cup. C.) Place a washcloth in the sink before beginning the cleansing. D.) Scrub them with the patient's toothbrush and toothpaste.

C [Place a washcloth in the sink before beginning the cleansing.]

Chapter 18 (study guide) You are caring for a patient who has had an abdominal hysterectomy. In helping reposition this patient, you will be sure to: A.) Position the patient in Fowler's position. B.) Raise the knees 15° to relieve pressure on the abdominal incision. C.) Position the patient in semi-Fowler's position. D.) Position the patient in the prone position.

C [Position the patient in semi-Fowler's position.]

Chapter 17 (study guide) When pouring a sterile liquid you should: A.) Pour in short batches so as not to splash. B.) Pour with the label away from the palm of the hand. C.) Pour with the label toward the palm of the hand. D.) Place the cap open side down on a sterile surface.

C [Pour with the label toward the palm of the hand.]

Chapter 16 (text book) Medical asepsis differs from surgical asepsis in that medical asepsis is aimed at: A.) Sterilizing all equipment. B.) Killing all microorganisms. C.) Preventing transmission of microorganisms D.) Preventing entry of microorganisms into the body.

C [Preventing transmission of microorganisms]

Chapter 17 (study guide) The emphasis of protective environment isolation is to: A.) Protect the health care workers from infectious organisms. B.) Prevent the transfer of microorganisms outside the patient's environment. C.) Protect the patient from microorganisms in the hospital environment. D.) Build up the patient's immunity to normal flora.

C [Protect the patient from microorganisms in the hospital environment.]

Chapter 16 (website) A wound is infected by a multidrug-resistant organism. In the infections chain, the wound is considered link two, otherwise known as: A.) Mode of Transfer B.) Causative Agent C.) Reservoir D.) Portal of Exit

C [Reservoir]

Chapter 16 (study guide) In the home care setting, contaminated dressings should be handled by ____________ before disposal. A.) Boiling them for 10 minutes B.) Treating them with a 1:10 chlorine solution C.) Securing them in plastic zip-closure bags. D.) Washing in hot soapy water.

C [Securing them in plastic zip-closure bags.]

Chapter 21 (text book) The nursing assistant reports tot he nurse that the temperature of a patient who is first-day postoperative is 100.2°F. Which action should the nurse take first? A.) Notify the surgeon of the temperature elevation. B.) Check the preoperative temperature reading. C.) Tell the nursing assistant to take the temperature again in 2 hours. D.) Prepare to administer an acetaminophen PRN-ordered suppository.

C [Tell the nursing assistant to take the temperature again in 2 hours.]

Chapter 17 (text book) A patient under Contact Precautions wants to know if he may have visitors. The nurse tells him that: A.) Visitors may come but they must wear a mask and gown B.) There are no special requirements for people visiting a patient under Contact Precautions. C.) Visitors should check with the nurse to see whether they need to wear PPE. D.) Visitors may come but should wash their hands before and after socially touching the patient.

C [Visitors should check with the nurse to see whether they need to wear PPE.]

Chapter 18 (text book) When changing the patient's position, it is most important to: A.) Use only those muscles absolutely necessary. B.) Stand with feet close together for greater strength. C.) Work at the same level or height as the patient. D.) Push rather than pull, as your weight helps.

C [Work at the same level or height as the patient.]

Chapter 20 (text book) A patient immobilized by a protective device is at risk for: A.) less attention from the staff. B.) muscle weakness and increased bone density. C.) constipation and impaired skin integrity. D.) reduced capillary refill distal to the device.

C [constipation and impaired skin integrity.]

Chapter 20 (study guide) A measure to promote patient safety after finishing a procedure is to: A.) explain the reason for the procedure. B.) elevate the head of the bed to semi-Fowler's position. C.) replace the bed in the lowest position. D.) tell the patient when you will return to the room.

C [replace the bed in the lowest position.]

Chapter 18 (study guide) The stoke patient has made very good progress in physical therapy. An order has been written to ambulate him with assistance. Before you assist him to walk for the first time, you help him dangle his legs. The reason(s) for this could be to: (select all that apply) A.) Strengthen his leg muscles before he stands. B.) Improve the circulation of the paralyzed leg and foot. C.) Help him recover from any dizziness. D.) Help him adjust to the change of position.

C, D [Help him recover from any dizziness.] [Help him adjust to the change of position.]

Chapter 17 (text book) The correct actions when donning a pair of sterile gloves include: (select all that apply) A.) Picking up the first glove by placing the fingers of the opposite hand under the cuff. B.) Smoothing the first glove over the hand before putting on the second. C.) Picking up the first glove by grasping it on the fold of the cuff. D.) Holding the glove with its fingers downward.

C, D [Picking up the first glove by grasping it on the fold of the cuff.] [Holding the glove with its fingers downward.]

Chapter 17 (text book) A home care nurse has a patient with a wound infection who is also under Airborne Infection Isolation Precautions. The patient's wife changes the dressing on the days that the nurse does not visit. The wound must be cleansed and then dressed. The nurse must teach the wife to: (select all that apply) A.) Maintain strict surgical asepsis. B.) Cleanse her hands and be careful to touch only the corners of the dressing with bare hands. C.) Store the used dressings and supplies in a sealed plastic bag before placing them in the trash. D.) Wear a mask as well as gloves when changing the dressing.

C, D [Store the used dressings and supplies in a sealed plastic bag before placing them in the trash.] [Wear a mask as well as gloves when changing the dressing.]

Chapter 19 (text book) A factor in skin problems common to elderly adults is: (select all that apply) A.) Skin tends to be dry because of increased gland activity. B.) Hair becomes thicker and grows more slowly. C.) Nails become thin and more brittle. D.) Fewer nutrients are available from the reduced diet. E.) Skin is less elastic and more fragile.

C, E [Nails become thin and more brittle.] [Skin is less elastic and more fragile.]

Chapter 20 (study guide) An important nursing action for the patient using wrist and ankle immobilizers is to: A.) allow only 4 inches of movement of each extremity. B.) offer fluids at 4-hour intervals. C.) check on the patient every 2 hours while immobilized. D.) document their removal and exercise every 2 hours.

D [document their removal and exercise every 2 hours.]

Chapter 17 A nurse is working in a small hospital with a combined medical-surgical unit. The only beds available are in two-bed rooms, and each room already has a patient. The recovery room nurse is about to send up a 25-year-old woman who just had her tonsils removed. Who would be the most appropriate roommate? A.) A 60-year-old woman, newly diagnosed with bacterial pneumonia. B.) A 23-year-old woman with a draining wound. C.) A 15-year-old girl who had oral surgery yesterday. D.) A 50-year-old woman recovering from an alcohol overdose.

D [A 50-year-old woman recovering from an alcohol overdose.]

Chapter 19 (text book) A stage III pressure ulcer is characterized by: A.) A partial-thickness skin loss involving epidermis and dermis. B.) A reddened area that does not blanch. C.) An area of induration. D.) A full-thickness skin loss that looks like a deep crater.

D [A full-thickness skin loss that looks like a deep crater.]

Chapter 18 (study guide) When performing ROM exercises for a stroke patient, you return the left arm to the side from a shoulder height lateral position. This movement is called: A.) Flexion B.) Abduction C.) Extension D.) Adduction

D [Adduction]

Chapter 16 (website) Which client is at high risk for infection? A.) A teenager with a closed ankle fracture. B.) An older patient with a stroke. C.) A middle-aged patient with a thyroid nodule. D.) An elderly patient with a central venous catheter (CVC).

D [An elderly patient with a central venous catheter (CVC).]

Chapter 16 (study guide) Effective disinfection of surfaces contaminated with blood and other potentially infectious material is accomplished by: A.) Scrubbing with soap and hot water for 3 minutes. B.) Soaking with 70% alcohol solution for 10 minutes. C.) Washing with iodine solution an then swabbing with alcohol. D.) Cleansing with a solution of 1:10 chlorine bleach and water.

D [Cleansing with a solution of 1:10 chlorine bleach and water.]

Chapter 16 (study guide) The liver participates in protection of the body against infection by: A.) Phagocytic action in the liver tissue. B.) Action of bile inactivating bacteria. C.) Flushing bacteria from the blood. D.) Destroying bacteria via the Kupffer's cells.

D [Destroying bacteria via the Kupffer's cells.]

Chapter 20 (text book) You are considering applying a protective device to your patient. What needs to be done first. A.) Obtain a physician's order. B.) Discuss your intentions with the patient. C.) Discuss your intentions with the family. D.) Determine that all other safety measures have been attempted to try to resolve the safety issue.

D [Determine that all other safety measures have been attempted to try to resolve the safety issue.]

Chapter 20 (text book) Humidity in the hospital is kept between 30% and %0% for the purpose of: A.) Maintaining skin moisture. B.) Keeping the staff comfortable. C.) Humidifying the air. D.) Discouraging microbial growth.

D [Discouraging microbial growth.]

Chapter 17 (study guide) When preparing a laboratory specimen for transport to the laboratory you would be certain to: A.) Place a label on the lid where it can be easily seen. B.) Place the specimen container in a clear plastic bag that can be securely closed. C.) Note your initials on the label. D.) Disinfect the specimen container if it is visibly contaminated.

D [Disinfect the specimen container if it is visibly contaminated.]

Chapter 19 (text book) A back rub should be offered to every patient because it: A.) Is an active form of exercise. B.) Increases medication absorption. C.) Is an expected nursing service. D.) Is relaxing and decreases tension.

D [Is relaxing and decreases tension.]

Chapter 16 (study guide) Giving a patient a serum immune globulin injection will provide: A.) Passive acquired immunity. B.) Naturally acquired passive immunity. C.) Artificially acquired immunity. D.) Passive artificially acquired immunity.

D [Passive artificially acquired immunity.]

Chapter 16 (text book) The most common method of microorganism transfer from one person to another in a hospital is prevented by: A.) Disinfecting instruments in special solutions. B.) Filtering the air in the hospital. C.) Changing bed linens daily. D.) Performing hand hygiene thoroughly and frequently.

D [Performing hand hygiene thoroughly and frequently.]

Chapter 16 (website) Which is considered the body's second line of defense against the invasion of pathogens? A.) Intact skin. B.) Cilia. C.) Kupffer cells. D.) Phagocytosis.

D [Phagocytosis]

Chapter 19 (text book) The extremities are washed from distal to proximal because this: A.) Promotes safety. B.) Cleanses the skin better than proximal to distal. C.) Supplies vital skin oils. D.) Promotes venous return to the heart.

D [Promotes venous return to the heart.]

Chapter 16 (text book) Passive acquired immunity is obtained by: A.) Exposure to a disease. B.) Immunization with response to the antigen. C.) Recovering from a disease. D.) Receiving an antitoxin or antiserum.

D [Receiving an antitoxin or antiserum]

The goal of nursing actions is the same for surgical asepsis and for protective isolation; that is to: A.) Confine the organisms to the infected patient. B.) Protect the nurse from infection. C.) Protect other people from microorganisms. D.) Reduce the microorganisms in the vicinity of the patient.

D [Reduce the microorganisms in the vicinity of the patient.]

Chapter 20 (text book) Which of the following findings BY ITSELF would indicate that a patient is at risk for falls? A.) Age over 70. B.) Patient is receiving insulin. C.) Visual impairment. D.) Slapping gait or lurching.

D [Slapping gait or lurching]

Chapter 20 (study guide) One measure to prevent nighttime wandering in older patients is: A.) administering sleeping medication at bedtime. B.) giving a back rub and warm milk at bedtime. C.) place the patient in a room with another patient. D.) increase daytime stimulation to decrease napping.

D [increase daytime stimulation to decrease napping.]

Chapter 16 (study guide) Match the terms in column I with the definitions in column II. Column I 1.) ___ Antimicrobial 2.) ___ Antiseptic 3.) ___ Asepsis 4.) ___ Contaminate 5.) ___ Debris 6.) ___ Disinfectant 7.) ___ Interferon 8.) ___ Pathogen 9.) ___ Prion 10.) ___ Protozoa 11.) ___ Sterile 12.) ___ Sterilization Column II A.) One-celled microorganism B.) Microorganism capable of causing disease C.) Process of destroying all microorganisms D.) Make unclean E.) Without pathogenic organisms F.) Freedom from pathogenic microorganisms G.) Protein particle that lacks nucleic acids H.) Dead tissue or foreign matter I.) Kills or suppresses growth of microorganisms J.) Chemical compound used on skin or tissue to inhibit growth of microorganisms K.) Agent that destroys microorganisms L.) Biologic response modifier that affects cellular growth

K J F D H I L B G A E C

Chapter 18 (study guide) The position most commonly used for inserting a rectal suppository is the _______ position. (fill in the blank)

Sims'

Chapter 19 (study guide) There are many factors that contribute to pressure ulcer formation. A contributing factor to pressure ulcer formation for the diaphoretic patient is __________ _____ _____. (fill in the blank)

constantly moist skin.

Chapter 17 (study guide.) You know that good ____ _______ is the best way to prevent the spread of infection. (fill in the blank)

hand hygiene