Nursing Exam 4-Chapter 24 Questions

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client? a. contact precautions b. droplet precautions c. neutropenic precautions d. airborne precautions

a

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? a. "I can leave my room any time I want as long as I wear a mask." b. "I will tell my visitors to keep their distance from me." c. "My personal belongings should remain in the room until I am discharged." d. "Any staff who enters my room will be wearing personal protective equipment (PPE)."

a

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing? a. In a bag marked "biohazards" b. With the double-bag technique c. In the sharps container d. In the client's trash container

a

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? a. noncommunicable disease b. infectious disease c. contagious disease d. communicable disease

a

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms? a. The client's immune system became further weakened b. The resident microorganisms mutated and became virulent c. The client's normal flora began producing spores d. The client's normal flora proliferated because of a nutritional deficit

a

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? a. The nurse removes her gown and then removes her gloves. b. The nurse performs hand hygiene after touching the client's surroundings. c. The nurse performs hand hygiene before putting on gloves. d. The nurse applies nonmedicated hand cream after performing hand hygiene.

a

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? a. Fungi b. Helminths c. Rickettsiae d. Protozoans

a

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? a. A commercially packaged surgical item is not considered sterile if past expiration date. b. Sterility may not be preserved even when one sterile item touches another sterile item. c. Any partially uncovered sterile package need not be considered contaminated. d. When a sterile item touches something that is not sterile, it may not be contaminated.

a

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism? a. Vehicle b. Droplet c. Airborne d. Direct contact

a

In which situation is an alcohol-based rub an inappropriate option for hand hygiene? a. When the nurse's hands are visibly soiled b. When the nurse leaves the room of an immunocompromised client c. When the nurse anticipates contact with the client's skin d. When the nurse is caring for a client with an active infection

a

The nurse has applied personal protective equipment (PPE) before caring for an immunocompromised client. When removing PPE, what action should the nurse perform? a. remove gloves touching only the inside of the glove, inverting one glove into the other b. remove gown pulling on the outside of the gown c. remove gloves, using the outside cuff to remove d. remove gown touching only the inside of the gown

a

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse? a. Discard the supplies and field and prepare a new sterile field. b. Remove the supplies from the field and replace with new supplies. c. Educate the client on sterile fields and continue preparing for the procedure. d. Give the client the water pitcher and continue preparation.

a

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? a. an older adult client with a history of heart failure b. a school-age child who is current with immunizations c. an adolescent who has a right radial fracture d. a middle-aged adult who takes prescribed medication to control blood pressure

a

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? a. The new nurse touches 1.5 in. (4 cm) from the outer edges. b. Direct visualization of the sterile field is maintained. c. The top flap of the package is opened away from the new nurse's body. d. The sterile field is set up at waist level.

a

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? a. removes gloves and walks out of the room b. asks the client to state name and date of birth c. applies a mask with face shield d. performs hand hygiene before donning gloves

a

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? a. Surgical asepsis b. Medical asepsis c. Universal precautions d. Contact precautions

a

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? a. one that remains in the client's room b. one that is the nurse's personal stethoscope c. one that remains directly outside the client's room d. one that the client has personally purchased for use

a

The nurse will assess a client who has a draining abscess. The nurse should perform what action to safely enter the room? a. don gown and gloves b. don gown and mask/face shield c. don gown, mask and protective eyewear d. don gown and face mask

a

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? a. contact b. airborne c. vector d. vehicle

a

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? a. wearing a particulate respirator for all client care and interaction b. placing the client in a regular, private room c. wearing a face mask when entering and staying at a distance from the client d. wearing protective eye wear for all client contact

a

The nurse is caring for an older adult client hospitalized with a hip fracture. Which nursing interventions will decrease the incidence of infection? Select all that apply. a. perform thorough skin assessment b. offer pneumococcal vaccine c. assess duration of catheter use d. encourage grandchildren to visit e. perform frequent hand washing

a, b, c, e

An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply. a. The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove. b.The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. c. The nurse places the sterile gloves on a clean dry surface at or below waist level. d. The nurse touches only the inner surface of the package and the gloves. e. The nurse opens the outside wrapper by carefully peeling the top layer back. f. The nurse places the inner package on the work surface with the side labeled "cuff end" furthest from body.

a, b, e

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diphtheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a, b, f

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a. The nurse puts on PPE after entering the patient room b. The nurse works from "clean" areas to "dirty" areas during bath c. The nurse personalizes the care by substituting glasses for goggles d. The nurse removes PPE after the bath to talk with the patient in the room

b

A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated? a. The nurse finishes cleaning a client's table. b. The nurse is caring for a client with a C. difficile infection. c. The nurse performs routine care and is moving to another client. d. The nurse finishes client care and hands are not visibly soiled.

b

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? a. It is the personal preference of the nurse whether or not to use clean technique b. The use of clean technique is safe for the home setting c. Surgical asepsis is the only safe method to use in a home setting d. It is grossly negligent to recommend clean technique for changing a wound dressing

b

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure? a. Report the incident to the appropriate person and file an incident report b. Wash the exposed area with warm water and soap c. Consent to PEP at appropriate time d. Set up counseling sessions regarding safe practice to protect self

b

A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

b

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? a. To protect staff members from becoming infected by clients b. To protect both the staff and clients from becoming infected by one another c.To protect clients from becoming infected by staff members d. To protect the hospital from legal liability

b

Question 1 of 5 Which client presents the most significant risk factors for the development of Clostridium difficileinfection? a. A client with renal failure who receives hemodialysis three times weekly b. An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis c. A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior d. A 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft

b

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? a. Good nutrition and getting enough rest b. Hand hygiene c. Avoid crowded areas and people who have the flu d. How to properly wear a mask during flu season

b

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? a. "We only wash our hands when they are visibly soiled." b. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." c. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." d. "Washing the hands with soap and water is not necessary."

b

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precaution should the nurse take? a. Implement full isolation protocol while client is contagious b. Use a mask when within 3 ft (1 m) of the client c. Use a gown when within 3 ft (1 m) of the client d. Ensure all visitors wash their hands upon entering the room

b

The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection? a. The client reports nausea and vomiting. b. Urine culture is positive for vancomycin-resistant enterococci (VRE). d. The nurse notes the client's urine is dark yellow with sediment. e. The unlicensed assistive personnel (UAP) documents the client's oral temperature as 99°F (37.22°C)

b

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? a. isolating the client's belongings b. changing the soiled dressing c. applying a face mask with shield d. wearing clean unsterile gloves when changing the dressing

b

The nurse is initiating isolation precautions for a client who has chronic Clostridium difficileinfection. What should the nurse be sure to include with these precautions? a. include a N95 respirator mask for health care staff entering the room b. be sure that there are gloves of various sizes and gowns for use c. recognize that this type of infection requires droplet precautions d. remind others to use a mask when caring for this client

b

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? a. with a client with a myocardial infarction b. into a private room c. with a client with pneumonia d. with another client with a draining wound

b

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? a. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. b. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. c. The nurse rinses thoroughly with water flowing away from the fingertips. d. The nurse uses soap and cold water to wash hands.

b

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? a. Shigella in the urinary tract b. Escherichia coli in the intestinal tract c. Escherichia coli in the urinary tract d. Shigella in the intestinal tract

b

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? a. fold soiled side to the outside and roll with outer surface exposed b. fold soiled side to the inside and roll with inner surface exposed c. fold soiled side to the inside and roll with outer surface exposed d. fold soiled side to the outside and roll with inner surface exposed

b

Which factor has contributed to resistant microbial strains? a. antibiotic use for bacterial infections b. use of antibiotics in clients with viral infections c. mutation of common disease-causing viruses d. use of topical antibiotics on skin abrasions

b

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? a. delivering a meal tray to a VRE-positive client without first donning gloves and a gown b. Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. c. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask d. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing

b

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? a. respirator mask and gown b. gown and gloves c. goggles and gloves d. mask and shoe covers

b

For which clients would the nurse be required to use droplet precautions? Select all that apply. a. a client with severe acute respiratory distress syndrome (SARS) b. a client with diphtheria prioritization c. a client with rubella d. a client with tuberculosis e. a client with mumps f. a client with metihicillin resistant staphylococcus aureus (MRSA)

b, c, e

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply. a. "If someone uses the bathroom after I have been on the toilet, he or she can catch the virus." b. "I may transmit the virus to my child during pregnancy and childbirth." c. "I may transmit the virus if I share needles with another person." d. "If I sweat at the gym and someone touches me, he or she can contract the virus." e. "If someone is exposed to my blood, I may transmit the virus to him or her."

b, c, e

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. Removes all jewelry including a platinum wedding band b. Washes hands to 1 in above the wrists c. Uses approximately one teaspoon of liquid soap d. Keeps hands higher than elbows when placing under faucet e. Uses friction motion when washing for at least 20 seconds f. Rinses thoroughly with water flowing toward fingertips

b, c, e, f

The nurse is caring for a client with third-degree, or full-thickness, burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply. a. Allow the client to only ingest fresh fruits or vegetables, no canned or prepackaged food products. b. Place the client in a private room with protective isolation. c. Permit flowers only if the containers have plastic wrapping around the base. d. Instruct all staff, the client, and family members to practice strict and meticulous hand washing. e. Restrict visitors to family members who are not ill.

b, d, e

The nurse caring for a client after hip surgery enters the room to take the client's vital signs. Which precaution should the nurse use? Select all that apply. a. Sterile gloves b. Hand hygiene c. Mask d. Gown e. Nonsterile gloves

b, e

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin? a. airborne b. none c. contact d. droplet

c

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? a. Don a second pair of sterile gloves over the first pair. b. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. c. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. d. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

c

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? a. sterile technique b. signs of healing c. hand washing d. putting on gloves

c

practice is a correct application of infection control practices? a. A nurse uses an alcohol-based hand rub each time that the nurse's hands are visibly soiled. b. A nurse dons a pair of gloves prior to any client contact. c. A nurse performs hand washing each time the nurse removes a pair of gloves. d. A nurse rinses hands thoroughly after the application of an alcohol-based hand rub.

c

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): a. virus. b. protozoa. c. fungi. d. bacteria.

d

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? a. avoid direct contact with the client b. wear a mask and gown in the client's room c. wear gloves when touching the client d. perform hand hygiene before and after entering the client's room

d

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down b. Hold the bottle inside the edge of the sterile field c. Hold the bottle with the label side opposite the palm of the hand d. Pour the solution from a height of 4 to 6 in (10 to 15 cm)

d

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? a. Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps b. Don a new pair of gloves to dispose of materials c. Wrap all used materials together and discard in biohazard container d. Perform hand hygiene

d

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? a. Only patients with diagnosed infections b. Only patients with visible blood, body fluids, or sweat c. Only patients with nonintact skin d. All patients receiving care in hospitals

d

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? a. Keep splashes on the sterile field to a minimum b. Cover the nose and mouth with gloved hands if a sneeze is imminent c. Use forceps soaked in a disinfectant d. Consider the outer 1 in of the sterile field as contaminated

d

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? a. Complete a sentinel event report. b. Notify the primary care provider. c. No action is needed. d. Don another pair of sterile gloves.

d

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? a. Wash the perineal area with soap and water b. Place water-soluble lubricant on catheter tip prior to insertion c. Ensure opening port of the catheter is closed d. Create an area for sterile field and opening packages

d

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? a. "Do not touch this, or I will have to start over. " b. "It's alright if you want to look at the supplies. Just be careful not to touch them." c. "Everything is ready, I will leave the tray here for the provider." d. "I've set up this sterile field for your procedure, so please do not touch anything around the tray."

d

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? a. sterile technique b. signs of healing c. putting on gloves d. hand washing

d

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention? a. offer the student a mask b. teach that a gown and shoe coverings must be worn in addition to gloves c. do nothing, as the precautions observed are appropriate d. remind the student that a fitted N95 respirator is required

d

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? a. Client with a diabetic foot ulcer b. Client with a surgical wound c. Clint with an intravenous catheter d. Client with a urinary catheter

d

Which piece of personal protective equipment (PPE) should be removed first? a. Gloves b. Respirator c. Goggles d. Gown

a

Any microorganism capable of disrupting normal physiologic body processes is a: a. bacterium. b. virus. c. pathogen. d. fomite.

c

The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which type of equipment? Select all that apply. a. Protective eyewear b. Sterile gloves c. Nonsterile gloves d. Gowns e. Masks

a, c, d, e

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. a. Pain b. Coolness c. Swelling d. Exudate e. Redness

a, c, d, e

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a. Providing a bed bath for a patient b. Visibly soiled hands after changing the bedding of a patient c. Removing gloves when patient care is completed d. Inserting a urinary catheter for a female patient e. Assisting with a surgical placement of a cardiac stent f. Removing old magazines from a patient's table

a, c, d, f

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? a. Perform hand hygiene before removing the gown. b. Avoid touching the outer surfaces of the gown. c. Remove the gown immediately after exiting the room. d. Remove the gown before removing gloves.

b

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse? a. fill out a risk management form b. wash the area with soap and water c. go to employee health for testing d. find out who left the scalpel blade on the procedure tray

b

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? a. The nurse performs hand hygiene before putting on gloves. b. The nurse removes her gown and then removes her gloves. c. The nurse applies nonmedicated hand cream after performing hand hygiene. d. The nurse performs hand hygiene after touching the client's surroundings.

b

Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes. a. false b. true

b

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? a. droplet b. airborne c. contact d. none

b

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. Remove gown, goggles, mask, gloves, and exit the room b. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles c. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene d. Remove goggles, mask, gloves, and gown, and perform hand hygiene

c

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? a. "I can't transmit the virus other people if I shake their hands." b."I received a blood transfusion in 1989, which could be a factor in contracting the disease." c. "I probably got the virus when I sat on the toilet seat in a dirty bathroom." d. "I may have gotten the virus when I got a tattoo while I was in prison."

c

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter? a. Remove all jewelry, including wedding bands, before hand washing. b. Use an alcohol-based hand rub to decontaminate the hands. c. Keep hands lower than elbows to allow water to flow toward fingertips. d. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips.

c

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? a. Remove the gown before removing gloves. b. Remove the gown immediately after exiting the room. c. Avoid touching the outer surfaces of the gown. d. Perform hand hygiene before removing the gown.

c

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? a. Ask another nurse to hold the hand of the patient and continue setting up the field b. Remove the instrument that was touched by the patient and continue setting up the sterile field c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand d. No action is necessary since the patient has touched his or her own sterile field

c

The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm3 c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c

The nurse determines that which client is at greatest risk for a wound infection? a. An infant with intact skin b. A client with a urinary catheter c. A two-day postoperative client d. An older adult client with dry skin

c

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? a. Request that the examination be done at the bedside. b. Question the need for the examination, because the client must remain under airborne precautions. c. Place a surgical mask on the client and transport to the CT department at the specified time. d. Notify the CT department in advance so other clients and staff can be removed from the area.

c

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? a. Change the sterile field, but reuse the sterile equipment. b. Proceed with the procedure since it was only touched by the client. c. Discard the sterile field and the supplies and start over. d. Call for help and ask for new supplies.

c

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? a. putting on sterile gloves before opening sterile package b. opening the sterile package toward the nurse to prevent reaching over c. keeping sterile field above waist level d. maintaining a 3-in. (7.5-cm) border around the sterile field

c

What is the primary purpose for the demonstrated glove application (gloves over the end of the gown sleeves)? a. Help adjust for glove size b. Minimize risk of a glove tear c. Cover exposed wrist skin d. Anchor gown sleeves

c

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do? a. Continue to utilize the bottle. b. Shake the bottle to ensure contents are mixed. c. Obtain a new bottle of sterile saline. d. Switch to sterile water.

c

Which action is the best example of a nurse donning/removing protective equipment properly? a. Donning respirator inside of client's room b. Removing gown after leaving client's room c. Removing respirator after leaving client's room d. Donning gown after entering client's room

c

Which client would the nurse consider the most infectious? a. A client who is in the incubation period b. A client who is in the convalescent period c. A client who is in the prodromal stage d. A client who is in the full stage of illness

c

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? a. Droplet precautions b. Medical asepsis technique c. Strict reverse isolation d. Surgical asepsis technique

d

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? a. Ensure that hard surfaces in the room are disinfected at least once per day. b. Use a private room with the door closed at all times. c. Place client in a private room that has monitored negative air pressure. d. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

d

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? a. Imbalanced nutrition b. Impaired physical mobility c. Chronic pain d. Infection

d

A nurse is caring for four clients. Which client has the highest risk of infection? a. young woman with a history of scoliosis b. toddler with a benign heart murmur c. woman in second trimester of pregnancy d. older male with an enlarged prostate

d

The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? a. airborne b. contact c. none d. droplet

d

Which should be documented by the nurse? a. The fact that the nurse washed her hands before a procedure b. The fact that the nurse donned gloves two different times during a procedure c. The specific items that the nurse transferred into a sterile field d. The fact that sterile technique was used for a given procedure

d