PPNC2 Exam 1 Practice Questions

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

A

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? A. Stop the blood transfusion and infuse saline B. Administer the prescribed antipyretic C. Obtain a prescription for an antihistamine D. Notify the blood bank about the symptoms

A

Which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? A. Stop the transfusion B. Obtain the vital signs C. Notify the HCP D. Maintain the flow with normal saline

A

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

A

Which nursing intervention is necessary before a blood transfusion is administered? SATA. A. Obtain the client's vital signs B. Monitor hemoglobin and hematocrit levels C. Allow the blood to reach room temperature D. Determine typing and crossmatching of blood E. Use a Y-type infusion set to initiate 0.9% normal saline

A, D, E

The nurse is changing the soiled bed lines of a client with a wound that is draining serosanguinous exudate. Which PPE would the nurse wear? A. Mask B. Clean gloves C. Sterile gloves D. Shoes covers

B

Which action should the nurse take to maintain sterility when performing a dressing change? A. Put the unopened sterile glove package carefully on the sterile field B. Remove the sterile drape from its package by lifting it by the corners C. Don sterile gloves before opening the package containing the field drape D. Pour irrigation liquid from a height of at least 3 inches (2.5 cm) above the sterile container

B

Which technique would the nurse use in attempting to glove the second hand when donning sterile gloves? A. Grasp the finger portion of the second glove and lift; then insert remaining hand into glove B. Insert gloved fingers under cuff of second glove and life glove; then slide ungloved hand into glove C. Using your gloved hand, grasp the folded edge of the second glove with two fingers and place glove on non dominant hand D. Don glove on non dominant hand first, then hold the glove away from the body and below waist to slide glove on

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? A. Wound asepsis B. Medical asepsis C. Surgical asepsis D. Concurrent asepsis

B

While receiving a blood transfusion, a client develops flank pain, chills, and fever. Which type of transfusion reaction would the nurse conclude that the client is experiencing? A. Allergic B. Pyrogenic C. Hemolytic D. Anaphylactic

C