NUR245 exam 1 practice questions

Which statement made by the student nurse about precautions to take when treating a client with open burn wounds indicates the need for further teaching? • "I should use nonsterile gloves when applying ointments." • "I should use nonsterile, disposable gloves when removing old dressings." • "I should wear personal protective equipment before caring for the client" • "I should remove personal protective equipment before leaving one client to treat

a

Which technique would the nurse use to maintain surgical asepsis? Change the sterile field after sterile water is spilled on it. Put on sterile gloves before opening a container of sterile saline. Place a sterile dressing no more than half an inch from the edge of the sterile field. Clean the surgical area with a circular motion, moving from the outer edge toward the center.

a

Thee nurse is caring for a client who underwent a hysterectomy and is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel AP)? Select all that apply. One, some, or all responses may be correct. Oral hygiene Assistance with bathing Oral medication administration Intravenous fluid administration Providing treatments with supervision

a b

You are going to perform a procedure. What considerations should be made regarding the choice of gloves? (Select all that apply.) The presence or absence of latex allergy Glove size Sterile or nonsterile procedure Whether the patient has a communicable disease

a b c

Which of the following are high-risk factors for latex allergy? Select all that apply. Food allergy to bananas, tomatoes, and peaches History of spina bifida Occupation as a food handler Food allergy to strawberries, shellfish, and peanuts Health care worker History of multiple surgeries History of respiratory disease

a b c e f

Question 1: You are assigned to a postoperative patient who underwent knee replacement surgery and had an ankle pinned. You must perform a dressing change and provide pin care, which requires creating and maintaining a sterile field. What would be evidence of the patient meeting the expected outcome 24 hours after the procedure? (Select all that apply.) Afebrile WBC within normal limits of 5000 to 10,000 per mm3 Purulent drainage noted at pin site Absence of tenderness or edema at surgical sites

a b d

15. The nurse observes the following during the morning bath. Select the four findings that require follow-up. a. Red, swollen gums b. Smooth, pliable skin c. Patches of hair loss d. Ankle edema e. Reddened area on lower back f. Moist mucous membranes

a, c, d, e

Which precaution would be used for a patient with COVID-19? contact droplet airborne

airborne

Which precaution would be used for a patient with Mycobacterium tuberculosis? contact droplet airborne

airborne

Which precaution would be used for a patient with rubeola? contact droplet airborne

airborne

According to the basic rules of creating and maintaining a sterile field, which of the following is correct? A sterile field is prepared and covered with a sterile drape until ready to use. The sterile field is within your view. The sterile field is established immediately before the procedure to keep sterile from nonsterile instruments. Sterile and nonsterile items are placed on the sterile drape for use.

b

The expected outcome for wearing sterile gloves is: Prevention of contamination of a sterile field Prevention of localized or systemic infection Protection from exposure to blood/body fluids Fewer germs transmitted between patients

b

The health care team is delegated the task of assisting a client with bathing. Which member of the health care team is responsible and accountable for this aspect of client care? Nursing aide Registered nurse (RN) Patient care associate (PCA) Licensed vocational nurse (LVN)

b

A nursing instructor is reviewing sterile gloving with a group of students. Which statement, if made by a student, indicates correct understanding? (Select all that apply.) "Sterile gloves may replace hand hygiene if time is an issue." "Synthetic gloves may be used for individuals with a latex allergy." The powder in gloves prevents the passage of latex proteins. "Sterile gloves prevent the transmission of pathogenic microorganisms." "Sterile gloves should be used for procedures requiring medical asepsis."

b d

Which of the following outcomes are related to sterile gloving? (Select all that apply.) Blood pressure 120/80 Purulent drainage at treated site Weight 150 lbs WBC 15,000/mm3 Temperature 100.8° F (38.2° C) Pulse oximetry 99%

b d e

Which precaution would be used for a patient with Hepatitis A? contact droplet airborne

contact

Which precaution would be used for a patient with herpes simplex virus (HSV)? contact droplet airborne

contact

The use of standard precautions is determined by the patient's likelihood of carrying a communicable illness. True False

false

Which precaution would be used for a patient with pharyngeal diphtheria? contact droplet airborne

droplet

primary intention

wounds that heal under conditions of minimal tissue loss

secondary intention

wounds that require a lot more tissue replacement (open wound)

What method would the nurse use to evaluate the outcome of a sterile dressing change? (Select all that apply.) Ask the patient questions regarding the procedure to determine the patient's level of knowledge. Inspect the treated area for signs of localized infection. Evaluate the patient for signs of systemic infection.

b c

One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? Temperature of 102.5° F (39.2° C). Incisional area light pink in color. White blood cell count at 6500 per mm3. Absence of purulent drainage.

a

The nurse is caring for a two days post-surgery hip-replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next? Provide perineal care. Turn and position the client. Give a complete bed bath. Document the bowel movement,

a

The nurse is preparing to assist with a dressing change. An appropriate technique that the nurse includes in performing correct hand hygiene is to a. wash the wrists, then the hands. b. use a brush on the palms of the hands. c. maintain the scrub for at least 1 minute. d. wash well around watches and other jewelry.

a

The nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis? • Keeps the area free of microorganisms Confines microorganisms to the surgical site • Protects self from microorganisms in the wound Reduces the risk for growing opportunistic microorganisms

a

Column A- 1. Protein molecules on the surface of foreign invaders or nonliving substances such a. Antibodies as toxins, chemicals, drugs, or particles 2. Involves a defense by the white blood cells (WBCs), T lymphocytes, in response to foreign microorganisms 3. Freedom from and prevention of the contamination that causes infection 4. Any disease-causing agent 5. A process used to destroy all microorganisms, including their spores 6. Specialized cells that recognize foreign invaders 7. Organisms that live on or in other organisms 8. Animals that carry the pathogens from one host to another 9. A defense system that involves antibodies and WBCs that are produced to fight antigens 10. Group of non-disease-causing microorganisms, such as bacteria, fungi, and protozoa, that live within or on the body Column B- a. Antibodies b. Pathogen c. Vectors d. Cellular immunity e. Antigens f. Normal flora g. Humoral immunity h. Asepsis i. Sterilization j. Parasites

1. e 2. d 3. h 4. b 5. i 6. a 7. j 8. c 9. g 10. f

Column A- 1. A massage technique that employs long hand movements along the length of the back muscles 2. Unpleasant breath odor 3. Gums 4. Absence or loss of hair 5. Artificial part 6. Red, scaly areas with surface loss of skin tissue 7. Breakdown of the skin caused by fluid 8. Inflammation caused by friction 9. Armpit 10. Surfaces that line the passages and cavities of the body, such as nasal, oral, vaginal, urethral, and anal areas Column B- a. Alopecia b. Excoriation c. Maceration d. Chafing e. Mucous membranes f. Axilla g. Gingivae h. Effleurage i. Prosthetic j. Halitosis

1= h 2= j 3= g 4= a 5= i 6= b 7= c 8= d 9= f 10= e

Pathogen Reservoir Susceptible host Portal of exit Transmission Portal of entry 1. Current immunization status. 2. Sterilization of an object 3. Changing dressing and disposing in proper receptacle. 4. Performing hand hygiene 5. Covering a cough. 6. Maintaining skin integrity.

1= host 2= pathogen 3= reservoir 4= transmission 5= portal of exit 6.=portal of entry

Which nursing interventions require the nurse to wear gloves? Select all that apply. One, some, or all responses may be correct. Giving a back rub Cleaning a newborn immediately after delivery Emptying a portable wound drainage system Interviewing a client in the emergency department Obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)

b c

Which information would the nurse include when educating a group of daycare workers on infection control guidelines? Select all that apply. One, some, or all responses may be correct. Child pick-up Cleaning toys Hand hygiene Food preparation Medication administration

b c d

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? Don an N95 respirator mask before entering the room. Put on a permeable gown each time before entering the ream, Implement contact precautions and past appropriate signage. After finishing with client care, remove the gown first and then remove the gloves

a

Which precaution would be used for a patient with rubella? droplet standard contact airborne

d

When are sterile gloves necessary? When performing a sterile procedure. If blood or body fluids are present. If the patient is placed on isolation. When performing postmortem care.

a

Which client's care can be safely delegated to the unlicensed assistive personnel (UP) to provide oral hygiene? Dental caries Oral cancer Jaw fracture Thrombocytopenia

a

Which factor would the nurse consider when counseling an older adult on how often to take a tub bath? Condition of the skin Ability of the client to provide self-care Degree of orientation to the environment Type of allergic reactions experienced by the client

a

Which precaution would be used for a patient with AIDS? standard droplet airborne contact

a

tertiary intention

Wound that heals by drainage and suturing

For which physical assessment situation would the nurse use an alcohol-based hand sanitizer for hand hygiene? Before and after palpating a pulse Assessing a client with norovirus If the hand brushes a seeping dressing When the hands have contacted sputum

a

Which strategy is most effective for preventing the transmission of infection? • Wearing gloves and a gown • Applying face mask and a gown • Applying a face mask and gloves Wearing gloves and hand hygiene

d

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct. Lifestyle Occupation Chronic diseases Frequent traveling Diagnostic procedures

a b d

Which leukocyte value determines the adequacy of a client's response to inflammation? Select all that apply. One, some, or all responses may be correct. Monocytes Neutrophils Plasma cells T-helper cells Macrophages

a b e

Which nursing interventions enhance comfort in a dying client in the hospital? Select all that apply. One, some, or all responses may be correct. Frequently repositioning the client Maintaining oral hygiene in the client Limiting frequent visits of the family members Measuring the vital signs of client frequently Applying body lotion to the client's skin daily

a b e

Which statement regarding preventive measures for genital tract infections indicates the need for further education? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected "I should take frequent bubble baths." "I should decrease the use of dietary sugar." "I should choose hosiery with a nylon crotch." "I should use colored and scented toilet tissues." "I should limit the time spent in damp exercise clothes."

a c d

The nurse is developing a plan of care for a client who underwent extensive oral surgery for head and neck cancer. Which interventions would the nurse include in the plan to prevent infection? Select all that apply. One, some, or all responses may be correct. Protect incision site. Elevate head of the bed. Remove thick secretions. Offer small frequent feedings. Provide oral care at least every 4 hours.

a c e

Which of the following outcomes are related to sterile gloving? (Select all that apply.) Foul odor from wound Hemoglobin 14 g/dL Cyanosis Redness at wound site Increased warmth of skin at wound site Skin appears red and itches

a d e f

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of IV antibiotics? RBC count wound culture x-ray urinalysis

b

Which diagnostic test result indicates if a client will develop AIDS from HIV? level of IgM in blood number of CD4+ T helper cells available presence of antibody complex speed of virus

b

Which instruction would the nurse give to a client with reduced sensory perception? "Apply moisturizer." "Use a bath thermometer." "Dress warmly in cold weather." "Avoid frequent bathing"

b

Which nursing intervention would the nurse implement for a client with active tuberculosis who is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions? Ensure regular visits by staff members to meet the client needs. Explore what the airborne precautions mean to the client. Report the situation to the infection control nurse immediately. Reteach the concepts of airborne precautions to the client.

b

Which precaution would be used for a patient with MRSA? droplet contact airborne standard

b

Which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? Wound asepsis Medical asepsis Surgical asepsis Concurrent asepsis

b

Which type of immunity will clients acquire through immunizations with live or killed vaccines? Natural active immunity Artificial active immunity Natural passive immunity Artificial passive immunity

b

While assessing the nails of a client with diabetes, the nurse finds the skin on the client's hands and feet are dry due to infection. Which rationale would the nurse associate with this dryness? • Applying moisturizing lotion between toes • Cutting nails after soaking them for 10 minutes in warm water Cutting nails straight across and even with the tops of the fingers or toes Using sharp objects to poke or dig under the toenail or around the cuticle

b

You are preparing a sterile field when you realize you will need more sterile gauze for the dressing change. What action should you take? Go and get more sterile gauze before initiating the actual dressing change. Turn on the call light and request more sterile gauze from the person that responds. Discard the sterile field and its materials, obtain the necessary supplies, and start over. Perform the dressing change using what sterile gauze is available.

b

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? Insert a urinary catheter. Initiate droplet precautions. Move the client to a private room. Use a high-efficiency particulate air (HEPA) respirator during care.

c

Which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men? • Inadequate fluid intake • Poor hygienic practices The length of the urethra The disruption of mucous membranes

c

Which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date on required immunizations for school? • 'By this time your child has developed sufficient antibodies to provide immunity: • 'Maintaining current immunizations is critical. Make sure the series is completed! 'This isn't the best time to finish the immunizations, because your child's immune system is suppressed.' 'It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal.

c

Which precaution would be used for a patient with herpes zoster? standard droplet contact airborne

c

Which type of isolation precautions would the postpartum nurse plan to implement for a client who has given birth by urgent cesarean section related to active herpes simplex virus (genitalia) following onset of labor and rupture of membranes 8 hours ago? Standard Droplet Contact Airborne

c

Which finding in the older adult client is associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct. Dysuria Urgency Confusion Incontinence Slight rise in temperature

c d e

The nursing student is preparing to do a sterile dressing change. The patient has a reported allergy to latex. What should the nursing student do at this time? Check to see if patient's allergy is listed in the patient's medical record. If the patient denies allergy to strawberries or peanuts, go ahead with the procedure. Don't wear gloves at all. Change gloves to synthetic or nonlatex glove

d

Which complication is prevented from occurring by performing punctal occlusion after the administration of eyedrops? tearing infection allergic reaction systemic absorption

d

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? The nurse understands the client has pain due to a tracheostomy. The nurse identifies the client is anxious about the cardiac catheterization. The nurse realizes the client has diarrhea and needs the bedpan frequently. The nurse identifies the client is not aware of perineal care and has impaired skin integrity.

d

Which evaluation method is the most effective way for the nurse to evaluate the teachers' knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques? Observe the teachers lecture the children about hand hygiene. Administer an objectively written final examination to the teachers. Have the teachers share their knowledge of hand washing. Watch the teachers demonstrate infection-control techniques.

d

Which precaution would be used for a patient with HIV? contact airborne droplet standard

d

Place the following in the correct order for handwashing. a. Wrists b. Fingertips and under the nails c. Palms d. Fingers e. Back (dorsum) of the hands f. Between the fingers

c, e, a, f, d, b

Which description correctly identifies a health care-associated infection (HAI)? The patient receives IV antibiotics while hospitalized. The infection was not present at the time of admission. The six elements of the chain of infection remain intact. The patient is colonized with drug-resistant organisms.

b

40. A patient has a red, raised skin rash. During the bath, the priority action of the nurse is to a. assess for additional inflammatory reactions. h. discuss the body image problems created by the presence of the rash. c. wash the skin thoroughly with hot water and soap. d. moisturize the skin to prevent drying.

a

42. A nurse delegates the hygienic care of a male patient to the nursing assistant. In reviewing the patient assignment, the nurse instructs the assistant to make sure to use an electric razor to shave the patient with a. thrombocytopenia. b. congestive heart failure. C. Osteoarthritis D. Pneumonia

a

50. A patient on chemotherapy is experiencing stomati-tis. The nurse advises the patient to use a. baking soda, saline, and water rinses. b. a firm-bristled toothbrush. c. a commercial mouthwash. d. an alcohol mixture.

a

A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the patient's bladder. What link in the chain of infection is the nurse breaking by doing so? Portal of exit. Portal of entry. Reservoir. Host susceptibility.

b

A patient has a diagnosis of Clostridium difficile. What is most important for the nurse to convey to the NAP regarding this patient's care? To wash hands with soap and water before and after caring for patients with C. difficile. To use an alcohol-based hand rub after removing gloves. To wear an N95 mask when in the patient's room. To avoid caring for other patients with C. difficile to prevent cross contamination.

a

An adult female patient has been undergoing diagnostic testing since admission to the medical unit in the hospital. The results of blood testing are sent back to the unit. On reviewing the results, the nurse reports which abnormal finding to the physician? a. WBCs 14,000 cells/mm? b. Lymphocytes 2000 cells/mm? c. Neutrophils 65% d. Hemoglobin 14 g/dL

a

An adult patient has a viral infection. Which of the following vital signs is typical during the early stage of an infection? a. Increased blood pressure b. Normal temperature c. Decreased respiratory rate d. Increased oxygen saturation

a

The nurse is caring for four individuals. Which patient would be most at risk for infection? The patient who is receiving immunosuppressive medication. The patient who is unable to shower without assistance. The patient with a history of a latex allergy. The patient who exercises daily in a swimming pool.

a

The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? Following standard precautions. Using medical asepsis. Using surgical asepsis. Infection control to prevent a health care-acquired infection.

a

The patient has a large, deep abdominal incision that requires a dressing. When changing the dress-ing, the nurse accidentally drops the packing onto the patient's abdomen. The nurse should do which of the following? a. Throw the packing away and prepare a new one b. Add alcohol to the packing and insert it into the incision c. Pick up the packing with sterile forceps and gently place it into the incision d. Rinse the packing with sterile water and put the packing into the incision with sterile gloves

a

The single most important technique to prevent and control the transmission of infections is a. handwashing. b. the use of disposable gloves. c. the use of isolation precautions. d. sterilization of equipment.

a

Which of the following is a vector-borne disease? a. Rocky Mountain spotted fever b. Pneumonia c. Salmonella d. Hepatitis

a

Why are the hands rinsed with the fingertips held lower than the wrist? Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. To keep the sleeves from getting wet. It is necessary to ensure that all surfaces of the hands, including under the nails, are cleansed. To loosen and remove dirt and bacteria.

a

he nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: Surgical asepsis (sterile technique). Medical asepsis (clean technique). Droplet precautions. Standard precautions.

a

he nurse works in a small rural hospital with a wide variety of patients. Of the patients admitted this afternoon, the nurse recognizes that the individual with the highest susceptibility to infection is the individual with which of the following? a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease

a

Under which circumstance(s) should hand washing be repeated? (Select all that apply.) Hands touch the sink during hand washing. Areas under fingernails remain soiled. Cracked areas are noted on the nurse's hands. Hands are free of visible soiling. Hands are lowered below waist level.

a b

The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) Some of the sterile normal saline spills onto the sterile barrier. Nonsterile items are added to the sterile field. The nurse prepares the sterile field and leaves the room to get more sterile supplies. The nurse prepares the sterile field immediately before the procedure. When a sterile item falls off the sterile field, the nurse opens a new sterile item.

a b c

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following should be included in the discussion? (Select all that apply.) When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field. If there is any question or doubt of an item's sterility, the item is considered to be nonsterile. When using a sterile barrier, touch only the outer 2 inches (5 cm) of the border because this is considered nonsterile. When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field. When pouring a solution, if some spills onto the sterile barrier, cover the spill with sterile gauze.

a b d

When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) After adjusting a nasal cannula on a patient. After removing gloves after changing a wound dressing. When the nurse's hands are cracked from frequent hand hygiene. After moving patient's belongings on the bedside table After the patient develops a skin tear and blood is on the nurse's hand. When the patient has been diagnosed with C. difficile.

a b d

Which of the following are symptoms of latex allergy? (Select all that apply.) Skin redness. Itching. Purulent drainage. Edema. Difficulty breathing. Elevated temperature.

a b d e

When should you perform hand hygiene? (Select all that apply.) Before applying gloves to insert an IV. After documenting in the patient's electronic medical record. After moving a patient up in bed. Before assessing a patient's vital signs. Before touching clean linens.

a c d

A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase? (Select all that apply.) a. Nurse A wears artificial nails. b. Nurse B performs hand hygiene between patients. c. Nurse D has fingernails less than ¼ inch long. d. Nurse E has open cuts on her hand. e. Nurse F has chipped nail polish.

a d e

The NAP complains of his hands hurting and skin being chapped. What would be appropriate suggestions for the NAP? (Select all that apply.) Use hand lotion from an individual use container. Decrease the frequency of hand hygiene until healed. Wear clean latex-free gloves at all times. Be sure to rinse and dry hands thoroughly Avoid excessive amounts of soap or antiseptic.

a d e

Which of the following patients are at risk for developing an infection? (Select all that apply.) A patient receiving chemotherapy. A patient who has an early discharge from the hospital. A patient in a private A patient with a chronic respiratory disease receiving steroid therapy.

a d e

A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse's best action? Discard the needle, syringe, and medication and start over. Discard the needle and replace with a new one before administration. Wipe the needle with an alcohol swab and recap for use. Transfer the medication to a new syringe.

b

The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) Standard precautions are used to protect you from potential contact with blood and body fluids. Standard precautions should be observed in every patient encounter. Standard precautions refer only to the use of gloves, not to the use of masks, eye protection, or gowns; these refer to other types of precautions. To follow standard precautions, you must wear sterile gloves. Standard precautions are used once the type of infection is identified.

a, b

It is determined that the patient has developed a health care-associated infection of Pseudomonas pneumonia that developed from the presence of contaminated water and a dirty health care environment. What measures can be taken to help break the chain of infection? (Select all that apply.) Performing hand hygiene before and after contact with the patient Discarding standing water and rinsing cups after use. Teaching the patient and family about the source and transmission of infections, the reason for susceptibility, and infection-control principles Having the patient wear an oxygen mask

a, b, c

A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A sterile barrier that has been permeated by moisture must be considered contaminated. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. A sterile field or object cannot become contaminated by air. If there is any doubt about an item's sterility, the item is considered to be unsterile. All items used within a sterile field must be sterile.

a, b, d, e

17. Which of the following are accurate statements about contact lenses and their care? Select all that apply a. Reusable lenses should be cleaned immediately after removing them. _ b. Lens solution can be reused if it appears clear and clean. c. Lenses are removed before administration of eye drops. _ d. Failure to properly care for lenses can lead to microbial keratitis. e. Removal and insertion of the left or right lens first should be alternated, . Lenses can be stored in any plastic container and solution.

a, c, d

A nurse reads the following documentation in a patient's electronic health record: 92-year-old female complains of frequent nonproductive cough. States has been taking PO steroids as prescribed. Denies having received pneumonia vaccine. B. Jones, R.N. Based on this information, what factors place this patient at risk for being a susceptible host? (Select all that apply.) Hospitalized. Nutritional status. Age. Gender. Vaccination status. Medical therapy.

a, c, e, f

36. Which of the following are correct in relation to shaving a patient? Select all that apply. a. Obtain consent from the patient to shave a beard or mustache. b. Apply cold water to the patient's face for 5 minutes before. c. Shave the patient in the direction away from the hair growth first._ d. Keep the skin taut and use short strokes. e. Document any nicks or cuts during the procedure.

a, d, e

41. The nurse is caring for a patient who has right-sided paralysis after a cerebrovascular accident (stroke). Which of the following factors would be most likely to result in pressure injury for this patient? a. Poor nutrition b. Reduced mobility c. Excessive hydration d. Skin secretions

b

44. A 61-year-old patient with diabetes mellitus has physician's orders for meticulous foot care. Which of the following is the best rationale for the order? a. The aging process causes increased skin break-down. b. There is peripheral neuropathy with this condition that places the patient at risk. c. The patient probably has a history of poor hygienic care. d. The lower extremities are difficult to see and therefore hard to maintain with good hygiene.

b

47. A patient has severe right-sided weakness and is unable to complete bathing independently. On the basis of this observation, the nurse identifies a nursing diagnosis/hypothesis of a. Low self-esteem. b. Hygiene self-care deficit. c. Altered tissue integrity. d. Lack of understanding of proper hygiene practices.

b

A nursing instructor is reviewing medical asepsis with a group of nursing students. Which comment, if made by a student, indicates that further teaching is needed? "Performing hand hygiene is an example of breaking the transmission link in the chain of infection." "Alcohol-based hand rubs should be used often when caring for patients with Clostridium difficile." "Health care-associated infections are most likely to develop in the urinary and respiratory tract." "Reducing the number of organisms and preventing their transfer is the goal of medical asepsis."

b

A patient is admitted with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) found in the sputum. In addition to using standard precautions, what action should the nurse take? Institute airborne precautions and place patient in a negative pressure airflow room. Institute contact precautions. Have the patient and visitors wear a mask at all times. No additional actions are necessary because the patient is already colonized with MRSA.

b

A patient is found to have MRSA. An appropriate isolation procedure for the nurse to implement when working with this patient is to a. leave all linen in the patient's room. b. use personal protective equipment for contact pre-cautions. c. wipe the stethoscope off before removing it from the room. d. identify on the patient's door that droplet precautions are in place.

b

A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? The patient probably has the flu. The patient may now have a systemic infection. The patient is displaying signs of a localized infection. The patient is experiencing an allergic response to his medication.

b

A patient was hospitalized for surgical repair of a fractured hip. Upon admission her lungs were clear to auscultation and she was afebrile. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has? A drug-resistant infection. A health care-associated infection. A systemic infection. A local infection.

b

A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that admission of this patient to the unit will require the implementation by the staff of a. droplet precautions. b. airborne precautions. c. contact precautions. d. protective isolation.

b

In evaluating the infection control measures used by the patient and family in the home, which finding indicates that additional teaching is required? a. Using antimicrobial soaps and disinfectants b. Sharing a towel in the bathroom c. Disposing of sharps in a jar with a screw-top lid d. Avoiding breathing directly on others

b

The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? The nurse discards the entire sterile field, all items on it, and starts over. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.

b

The nurse is applying sterile gloves. Which series of steps would require correction? Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.

b

The nurse recognizes that special care must be taken in the handling of which of the following to prevent the transmission of hepatitis C? a. Feces b. Blood c. Saliva d. Vaginal secretions

b

The nurse suspects that an older adult patient ma be experiencing hypostatic pneumonia. Older patients may react differently to infectious processes. so the nurse is alert to an atypical sign, such as Which of the following? a Hypotension b. Confusion c. Erythema d. Chills

b

The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? "Be sure to select appropriate size gloves. Gloves that are too small can tear more easily. "Once sterile gloves are applied, the inside of the glove is still considered sterile." "Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task. "If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair."

b

The parent of a preschool-aged child asks the nurse how chickenpox (varicella-zoster virus) is transmit-ted. The nurse identifies that the virus is transmitted a. by a vector organism. b. through the air in droplets after sneezing or cough-ing. c. through person-to-person contact. d. by contact with contaminated objects.

b

The patient has a 6-inch laceration on his right fore-arm. An infection develops at the site. Which of the following is a sign of a local inflammatory response observed by the nurse? a. Blanching of the skin b. Edema at the site c. Decrease in temperature d. Increase in the number of WBCs

b

To apply sterile gloves, the nurse applied the first glove on the right hand. Where should the nurse pick up the remaining glove? At the top edge of the cuff. Underneath the second glove's cuff. Anywhere, because the entire glove is sterile. You should pick it up with your ungloved hand.

b

What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? Bagging all linen. Performing hand hygiene. Keeping catheter bags empty. Wearing gloves.

b

nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? Washing hands with soap and water is the only effective means for stopping the spread of germs. Immunizations help protect children from being susceptible hosts. Large containers of hand sanitizer should be made available for use when there is visible soiling. Toys are typically the reservoir of pathogen growth.

b

The nurse is performing hand hygiene. Which would be an inappropriate action? (Select all that apply.) Keeping the hands and forearms lower than elbows. Using friction for 10 seconds in a vertical motion. Using hot water to rinse the hands after lathering. Turning the faucet off with a clean, dry paper towel. Drying hands from wrists to fingers with a paper towel.

b c e

An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) Her age. History of multiple surgeries as a child. Allergy to morphine and penicillin. Occupation. Use of a cane.

b d

The patient reports an allergy to latex. What alterations should be made in the patient's care? (Select all that apply.) Have a nurse who is also allergic to latex provide the patient's care. Use latex-free or synthetic gloves when gloves are necessary. Avoid wearing gloves unless absolutely necessary and only for short periods. Remove items that contain latex in the care of the patient. Avoid use of alcohol-based hand rubs. Determine whether syringes, IV tubing, and catheters contain latex.

b d f

The nurse is preparing a sterile field. The nurse opens the sterile commercial kit by pulling the outermost flap toward his body, followed by opening the remaining flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) The nurse correctly prepared the sterile field. Opening the outermost flap. Touching the outer edge of the sterile field. Adding sterile items to the field. Pouring a sterile solution.

b e

You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least 5 times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) The temperature of the water. The force of the water. The amount of soap used. The technique used in lathering. The position of your hands. The method used to turn off the faucet.

b f

The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? The NAP pushes his wristwatch and long uniform sleeves above the wrists. Standing in front of the sink, the NAP keeps his hands and uniform away from the sink surface. The NAP turns on the water and regulates the flow of water so that the temperature is warm and the force of the spray will not cause splashing. The NAP wets his hands and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing. The NAP applies 3 to 5 mL of detergent and rubs the hands together vigorously, lathering thoroughly. The NAP performs hand hygiene for at least 15 seconds, interlacing the fingers and rubbing the palms and back of hands with a circular motion at least 5 times each. The nurse rinses the hands and wrists thoroughly, dries the hands, and uses a dry paper towel to turn off the hand faucet.

c

Identify risk factors for this patient developing an infection. Select all that apply. Being discharged home Having chemotherapy Being malnourished Overcrowded health care facility IV insertion and blood sampling Resistance to antibiotics

b, c, d, e

According to the Centers for Disease Control and Prevention (CDC) Guidelines, an alcohol-based hand rub is used for routine decontamination in which of the following situations? Select all that apply. When a patient's mucus accidentally gets on the nurse's hand. Before having direct contact with patients. After contact with objects in the immediate vicinity of a patient. After a patient develops a skin tear and blood is present on both the patient and the nurse's hands. After removing gloves.

b, c, e

The nurse is observing a newly hired NAP on the unit. Under which of the following circumstances should the nurse reinforce the importance of hand washing and disinfection, and provide further instruction to the NAP regarding hand hygiene? Select all that apply. The NAP consistently performs hand hygiene before providing patient care. The NAP turns off the water faucet with her hand. The NAP uses warm water to wet her hands and hot water to rinse them. The NAP rinses the wrists and hands, keeping the hands down and the elbows up. When using an antiseptic hand rub, the NAP rubs hands thoroughly until they are dry. The NAP removes her gloves after assisting the patient with toileting and answers the next call light.

b, c, f

Which actions are considered part of standard precautions rather than transmission-based precautions? Select all that apply. a. Using a particulate respirator mask b. Discarding needles in a sharps container. c. Keeping live flowers and plants away from the patient d. Cleaning equipment after use e. Performing hand hygiene f. Using gloves

b, d, e, f

Which of the following statements are accurate in relation to infectious control? Select all that apply a. Women and girls have a greater risk for urinary tract infection. b. Patients with indwelling urinary catheters have a greater risk of infection. c. Infants are less susceptible to infection. d. Alcohol-based hand sanitizers are ineffective against Clostridium difficile. e. Immobility increases the risk for infection. f. Older adults are at a greater risk for skin infection.

b, e, f

46. To administer oral care to a semicomatose patient, the nurse should place the patient in which of the fol- lowing positions? a. Reverse Trendelenburg b. High Fowler with the head to the side c. Side lying with the head turned toward the nurse d. Supine with the neck slightly forward

c

48. The nurse is preparing to assist the semiconscious adult female patient with perineal care. The position of choice for this patient is a. sitting. b. side lying. c. supine. d. prone.

c

A nurse is observing a new staff member work with a patient. Of the following activities, which one has the greatest possibility of contributing to an HAI and requires correction? a. Washing hands before applying a dressing b. Taping a plastic bag to the bed rail for tissue disposal c. Placing a urinary catheter bag on the bed with the patient d. Using an antiseptic to cleanse the skin before starting an intravenous line

c

The nurse has prepared a sterile field and added the necessary sterile items to the field. The nurse has applied sterile gloves and is waiting to assist the health care provider in performing a surgical procedure. The nurse keeps the sterile field in view and holds her hands down at her side, away from her clothing. While waiting, the nurse instructs the patient to avoid touching the sterile field and for the need to lie still. Which action made by the nurse is incorrect? The patient teaching. Failing to cover up the sterile field with a sterile drape while waiting. Holding gloved hands at her side. All actions are appropriate.

c

The nurse is aware that it is important to break the chain of infection. Which of the following is an example of a nursing intervention that is implemented to control the portal of exit of infection for a patient? a. Using hand sanitizer b. Wearing disposable gloves c. Changing soiled dressings d. Administering vaccines

c

The nurse is observing the student put on sterile gloves. Which one of the following actions has contaminated the gloves? a. Keeping the package above waist level. b. Pulling the inner package edges apart with the thumbs and fingers. c. Grasping the second glove by the cuff. d. Adjusting the gloves by pinching and shifting with the other hand.

c

The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? Keep your intended work surface above waist level. Place the drape so the top half of the drape is over the top half of the work surface. You may grasp the outer 1-inch border of the drape without wearing sterile gloves Place sterile items onto the sterile field at an angle.

c

The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with surgical asepsis? a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedures. c. Sterile items are kept well within a 1-inch outer border of the field. d. Wrapped sterile packages should be opened, starting with the flap closest to the nurse.

c

Which of the following is a correct description of glove removal? You pull the gloves off by the fingertips and discard them in a proper receptacle. You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand under the cuff of the dominant hand and pull the glove off and discard.

c

Which of the following are symptoms of a systemic infection? (Select all that apply.) Redness. Edema. Fatigue. Fever. Pain or tenderness. Nausea and vomiting.

c d f

The nurse is observing the NAP perform hand hygiene. Which of the following, if performed by the NAP, requires intervention by the nurse? (Select all that apply.) The NAP: Washes her hands before and after removing clean gloves. Applies 3 to 5 mL of antimicrobial soap to hands wet with warm water. Takes the patient's blood pressure and leaves the room to document. Washes hands with plain soap and water when visibly dirty. Puts the patient's socks on, then begins to feed the patient. Moves the patient's IV pole by the bed and uses hand sanitizer. Has an uncovered cut on the back of the nondominant hand.

c e g

When putting on personal protective equipment (PPE), the correct order is: a. Gloves b. Mask c. Gown d. Goggles/eyewear

c, b, d, a

The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? (Select all that apply.) Use sterile gloves if anticipating contact with nonintact skin. Artificial nails should be no longer than 0.625 cm (1/4 inch). If worn, fingernail polish should not be chipped. Cough hygiene practices should be followed. Gown and gloves are sufficient PPE for a splash risk. Always know a patient's susceptibility to infection.

c, d, f

43. The nurse delegates morning care to a new certified nursing assistant. Which of the following actions by the assistant would be evaluated as appropriate? a. Placing dentures in a tissue while not worn b. Cutting the patient's nails with scissors c. Using soap to cleanse around the eyes d. Washing the patient's legs from the ankle to the knee

d

45. A nurse is instructing a patient with peripheral vascular disease about daily foot care. The nurse's instruction for the patient includes a. soaking the feet 5 to 10 minutes each day. b. filing the nails into a curved shape. c. using commercial corn removers if needed. d. applying lotion to the feet.

d

49. The nurse is completing a bed bath for a dependent adult male patient. During the perineal care, the patient has an erection. The nurse should a. tell the patient just to relax. b. indicate that the bath cannot be continued. c. ask the patient to do the care as well as he can. d. defer the care until later in the bath.

d

A nurse is obtaining a patient's medical history when he states, "I am HIV positive because I shared needles with a friend who is also HIV positive." The friend would be considered: The susceptible host. The vehicle or route of transmission. The infectious agent. The reservoir.

d

A patient requires a sterile dressing change for a midabdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to a. put sterile gloves on before opening sterile pack-ages. b. place the cap of the sterile solution well within the sterile field. c. place sterile items on the edge of the sterile drape. d. discard packages that may have been in contact with the area below waist level.

d

An NAP asks what an example would be of using standard precautions. The nurse is correct to respond: Placing an "isolation precautions" sign on the patient's door to alert any visitors. Wearing gloves and a mask whenever it is known that a patient has a communicable illness. Collecting a sputum specimen to determine if an infection is present. Wearing clean gloves when emptying a bedpan

d

The nurse changes the dressing of your first patient with methicillin-resistant Staphylococcus aureus of the wound. The nurse discards the gloves and goes into the next room, where the nurse suctions a second patient's airway. According to the chain of infection, the mode of transmission is: Methicillin-resistant Staphylococcus aureus. The first patient. The first patient's wound. The nurse The second patient's respiratory tract. The second patient.

d

The nurse employs surgical aseptic technique when a. disposing of syringes in puncture-proof containers. b. placing soiled linens in moisture-resistant bags. c. washing hands before changing a dressing. d. inserting an intravenous catheter.

d

The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? The nurse reviews documentation to see what supplies will be needed. The nurse asks the patient to rate his pain on a pain scale. The nurse asks the patient if he needs to use the bathroom. The nurse asks the patient if he has ambulated in the hall today.

d

The nursing student is preparing a sterile field to insert a Foley (urinary) catheter in a patient. While adding the sterile catheter to the sterile field, it accidentally touches the patient's bedding. The student has added the catheter to the sterile field. What is the best action for the nursing student to take at this time? Remove the catheter from the field and obtain a new one. Apply water-soluble lubricant to the end of the catheter and continue with the procedure. Apply a sterile drape over the bedding. Discontinue field preparation, and start over with new equipment.

d

The unit manager observes the new staff nurse perform the following actions for a patient with isolation precautions. Which of the following actions should the unit manager address and correct with the new nurse? a. Keeping a thermometer, stethoscope, and blood pressure cuff in the patient's room. b. Documenting the precautions required in the patient's record. c. Using a particulate respirator mask for the patient who has tuberculosis. d. Coming out of the room in the PPE to quickly get another dressing.

d

You include performing hand hygiene in your nursing care to help break the chain of infection. At which link in the chain of infection is hand hygiene primarily effective? Pathogen Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host

d

31. Place the following steps for a bed bath in the correct order. a. Washing the legs _ b. Washing the arms and hands c. Perineal care d. Washing the back e. Cleaning the eyes f. Washing the chest and abdomen g. Washing the face, ears, and neck

e, g, b, f, a, c, d

"Standard precautions" means that you should use gloves, mask, eye protection, and a gown when a patient is placed on isolation. True False

false Standard precautions include the use of gloves, masks, eye protection, and gowns when there is a risk of being splattered with infectious materials regardless of the location of a patient.

Standard precautions are used to protect you from potential contact with blood and body fluids. True False

true