Test 1

Question 1

Which steps are appropriate when utilizing an alcohol-based hand hygiene product?

1. apply a palmful of product into a cupped hand- enough to cover all surfaces of both hands
2. rub palm against palm
3. interface fingers palm to palm
4. rub palms to back of hands
5. rub all surfaces of each finger with the opposite hand
6. continue for about 10 to 15 seconds

Answer 1

1, 2, 3, 4, 5

Question 2

A nurse is receiving a manicure. What directions given to the manicurist are acceptable?

1. short polished nails
2. unpolished artificial nails
3. squarely filed nails
4. intact cuticles

Answer 2

1,3,4

Question 3

A nurse is performing hand washing after administering intravenous medication. Which action is inconsistent with proper technique?

1. The use of warm water to wash
2. the use of firm rubbing and circular movements to wash
3. The use of a paper towel to vigorously scrub hands dry
4. The use of a new paper towel to turn off the faucet

Answer 3

3

Question 4

In which instance would the nurse not need to use standard precautions?

1. caring for a client with oozing leg edema
2. performing oral care on a client
3. caring for a diaphoretic client with chest pain
4. Performing a dressing change on a client with diabetes

Answer 4

3

Question 5

A student nurse is describing different forms of PPE. Which statement, if made by the student, indicates the need for further education?

1. I will wear clean gloves to protect my hand when I handle any potentially infected material
2. Since I wear prescription glasses at work, I do not need to wear goggles
3. I will wear a sterile gown when I change the dressing of a client with burns
4. Even though I wear gloves, I still cleanse my hands after removing my gloves because my hands may have become contaminated.

Answer 5

2

Question 6

A nurse is preparing to assist with a chest tube insertion on a client. Which nursing cation demonstrates that further teaching regarding safety measures is indicated.?

1. The nurse reviews the primary care providers order for the procedure
2. The nurse measures and records vital signs before the procedure
3. The nurse arranges for someone to care for the other assigned clients
4. The nurse delegates setup of the sterile field to the unlicensed assistive personnel

Answer 6

4

Question 7

A nurse has just finished assisting a physician with a procedure. Which elements should be included in the nurse documentation ?

1. exact procedure, including date and time
2. client response to the procedure
3. vital signs before and after the procedure, including pain assessment
4. method of disposing of used supplies
5. any client teach that was offered.

Answer 7

1,2,3,5

Question 8

A nurse is preparing to enter a room where full PPE is required. Which technique, if done by the nurse, indicates a good understanding of infection prevention principles?

1. The nurse pulls the gloves up to cover the cuffs of the gown
2. the nurses mask covers the mouth but not the nose
3. the nurse fastens the ties on the gown without overlapping the gown edges
4. the nurse applies a mask that has been used no more than once before.

Answer 8

1

Question 9

When the nurse returns to follow up with a home care client 2 days after the insertion of an indwelling catheter, the client has cloudy urine, has a low grade fever, complains of lower abdominal discomfort. The nurse recognizes the client most likely has developed a UTI, which is what type of infection?

Answer 9

Health-care associated

Question 10

While dressing for work, the nurse discovers all of her favorite uniforms are dirty. The nurses best strategy would be?

Answer 10

wear a clean uniform even if it not her favorite

Question 11

The nurse knows that any substance can serve as an intermediate means to transport and introduce an infectious agent into a susceptible host through a suitable portal of entry. Which term best describes this type of transmission

Answer 11

Vehicle-borne transmission

Question 12

which statement if made by a nurse indicates the need or further teaching about the six links in the chain of infection?

1. the goal of infection prevention measures is to break the chain whenever and wherever possible so that disease is not transmitted from one person to another
2. direct transmission can occur through touching, biting, kissing, or sexual intercourse
3. airborne transmission may involve droplets or dust
4. direct transmission can be either vehicle-borne or vector borne.

Answer 12

4

Question 13

A nurse is preparing to establish a sterile field. Which technique if done by the nurse could compromise the maintenance of the sterile field.

1. use of a package that has condensation in it
2. placement of the package so that the top flap of the wrapper opens away from the nurse
3. dropping sterile items on the field so that they land more than 2.5 c from the border of the field
4. reaching around rather than over the field.

Answer 13

1

Question 14

which technique of applying sterile gloves indicates a good understanding of this technique ?

1. place the package of gloves on a clean dry surface
2. open the outer package without contaminating the floes or the inner package
3. put the first glove on the nondominant hand
4. pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm.
5. once both gloves are on, unroll any portion of the cuff that had been caught during the application.

Answer 14

1,2,4

Question 15

A nurse is caring for a patient with TB. The transmission based precautions used are in addition to standard precautions which of the following would the nurse use and be consistent with infection prevention guidelines?

1. surgical mask at all times while in the clients room
2. am N95 respirator mask when within 3ft of the client
3. Gloves for all contact with the client
4. Hand hygiene before applying and after removing gloves
5. a gown when performing a physical examination of the client

Answer 15

2,4

Question 16

A nurse is assigned to care for a client on a contact precautions. Which action by the nurse would require immediate intervention on the part of a supervisor?

1. the nurse changes gloves after contact with infectious material
2. the nurse places used disposable sharps directly into designated sharps container
3. the nurse removes the used gown outside the clients room
4. the nurse sends a specimen to the laboratory in a plastic container with a secure lid, and in a plastic bag

Answer 16

3

Question 17

In delegating to unlicensed assistive personnel, which task would need to be completed only by the registered nurse?

1. caring for a client on standard precautions
2. collecting a urine specimen from a client who is infectious
3. performing a sterile procedure on a client on contact precautions
4. caring for a client on airborne precautions

Answer 17

3

Question 18

The nurse caring for a client on droplet precautions is preparing to document care of that client. Which aspects of care should the nurse document in the narrative notes?

1. characteristics of a productive cough
2. which aspects of care were delegated to UAP
3. treatments provided by the respiratory therapist
4. oral and skin hygiene

Answer 18

1

Question 19

a client is HIV positive, taking antiviral medications as ordered and has no HIV related problems. The client is being admitted for an appendectomy. what type of precautions would be required when caring for the client

Answer 19

Standard precautions

Question 20

The nurse is caring for several clients requiring transmission based precautions. which of the following skills could the nurse safely delegate to the unlicensed assistive personnel?

1. explaining isolation requirement to a client in airborne isolation
2. teaching the parents of a child in isolation how to follow the necessary precautions
3. obtaining vital signs from a client in airborne isolation
4. transporting a client requiring standard reactions to radiology.
5. instructing a client who has been on airborne precautions for discharge.

Answer 20

3, 4

Question 21

which of the following tasks can be delegated to unlicensed assistive personnel?

1. vital signs for a client just admitted to the floor from a nursing home
2. a client who needs an apical pulse checked prior to medication administration
3. vital signs for a client just returned to the floor from dialysis
4. a client who need a tympanic temperature taken
5. blood pressure for a client whose last two BPs were 98/72 and 85/60

Answer 21

1,3,4

Question 22

The nurse is assessing the students skill set in taking blood pressure. which observation if made by the nurse required intervention so that the student takes proper measurements?

1. the student nurse has the client hold his arm out from his body at shoulder level while taking the reading
2. the student nurse has the client place his arm at the level of the heart while taking the reading
3. the student nurse allows 1 to 2 mins between readings if unsure of the numbers
4. the student nurse allows the client to rest after finishing eating before taking a blood pressure.

Answer 22

1

Question 23

a nurse is teaching a group of nursing students the differences in pulse and respiration readings across the life span, which statement if made by a nursing student, indicates the need for further teaching

1. an average pulse rate for a teenager is 100 BPM
2. an average range of respirations for a newborn is 30-80 breathes per minute
3. an average pulse for a 1 year old is 80-140 BPM
4. an average respiration rate for an older adult is 16 breaths per minute

Answer 23

1 (the average is 75 BPM)

Question 24

a clients blood pressure reading is 144/96 . In which classification does this blood pressure reading qualify

1. normal
2. prehypertention
3. hypertension, stage 1
4. hypertension, stage 2

Answer 24

3

Question 25

a nurse is considering the different sites for body temperature measurement. Which statement regarding site choice for body temperature requires further instruction or clarification? 1. Although oral temperatures are accessible and convenient, they are inaccurate if the client has just smoked or eaten 2. rectal thermometers are a reliable measurement even in the presence of stool 3. temporal artery measurements are safe, noninvasive, and very fast 4. tympanic membrane readings are readily accessible, reflect the core temperature and are very fast

Answer 25

2

Question 26

the nurse is preparing to take a pulse on a client who is receiving digoxin, which affects the heart rate. This assessment needs to be completed prior to medication administration. Which skill is correct when assessing the pulse of this client? 1. a radial pulse taken for 15 seconds 2. a femoral pulse taken for 30 seconds 3. a carotid pulse taken for a full minute 4. an apical pulse taken for a full minute

Answer 26

4

Question 27

The nurse is teaching a nursing student about blood pressure measurement. which statement if made by the nursing student, demonstrates the need for further teaching? 1. if the client is sitting in a chair, i should make sure that both feet are flat on the floor 2. after i locate the brachial artery, i should wrap the deflated cuff evenly around the upper arm. 3. i should pump up the cuff until the sphygomomanometer reads 30 above the point where the brachial pulse disappeared 4. after i hear the first heart sound. i should release the valve on the cuff rapidly so as not to injure the client.

Answer 27

4

Question 28

which action performed by the nurse demonstrates proper measurement of oxygen saturation? 1. the nurse ensures that the LED and photo detector face each other 2. the nurse uses the finger for a pulse oximetry reading on a client with dark nail polish 3. the nurse moves the spring sensor on the clients finger every 12 hours 4. the nurse documents the pulse rate daily using only the oximeter

Answer 28

1

Question 29

a nurse is documenting the respiratory assessment on a client who has just undergone a bronchoscopy. In addition to the respiratory rate, which components should be included in the nurses note. 1. character of respirations 2. depth, rhythm, and character of respiration 3. rhythm of respirations arterial blood gases, rhythm and depth of respirations

Answer 29

2

Question 30

The nurse enters the clients room and sees the client visiting with family members, laughing with them, and watching TV. The client informs the nurse that he is in a great deal of pain and believes it is time for his pain mediation. How would the nurse document this interaction? 1. client says he is in pain but he is laughing with his visitors and watching TC 2. client reports pain but his is laughing and watching TV with visitors 3. client reports pain and requests medication. Client and visitors watching TV and laughing. 4. Client reports pain but does not appear to be in any distress. Laughing and watching TV with visitors.

Answer 30

3

Question 31

The nurse is preparing to administer a full agonist analgesic and recognizes which the following characteristics for this type of analgesic? 1. it should not be administered to clients who are terminally ill 2. its dose can be steadily increased as needed to relieve pain 3. there is no max daily dose limit 4. there is no ceiling on level of analgesia from this drug 5. an example of this type of analgesic would include morphine, oxycodone, or hydromorphone

Answer 31

2,3,4,5

Question 32

an 86 year old client is restless and moaning. His daughter states the client did not sleep well during the and and he seems to be confused at time. what is the nurses first action? 1. administer the clients prn analgesic 2. ask the client if he wants a sleeping pill 3. ask the daughter to stay and watch her father in case he become more confused 4. determine whether the client can pride a self-report of pain.

Answer 32

4

Question 33

a client with a history of chronic low back pain has not been able to obtain effective pain management. Which does the nurse see as a barrier to pain management? 1. the client refuses to take any drug that has the potential to be addictive 2. the client has mo allergies to medications 3. the client has been actively participating in physical therapy 4. the client visits the doctor every 3 months

Answer 33

1

Question 34

The nurse is caring for a postoperative client who is complaining of pain and requests a nonnarcotic pain reliever. The nurse suggests a narcotic analgesic would be more effective. The client responds by saying she doesn't want to be "doped up" when her family comes to visit and will take the narcotic after the last family member leaves for the day. Which would be the nurses best action? 1. administer the narcotic analgesic anyway because the nurse knows that would be the best thing for the client 2. administer the nonnarcotic analgesic as requested and meet the family member visiting in the hall to suggest a short visit so the narcotic analgesic can be given sooner 3. administer the nonnarcotic analgesic as requested, instruct the client to call if the pain become unmanageable and reassess the client within 30 minutes 4. explain to the client why she should take the narcotic analgesic and that family visits will be suspended for the day if she insists on the nonnarcotic analgesic

Answer 34

3

Question 35

the nurse enters the postoperative clients room to assess the client and finds vital signs are normal, the wound dressing is dry and intact, and the client did not complain of pain. what did the nurse forget? the nurse should have: 1. changed the clients bed linen 2. administered an analgesic prophylactically to prevent unmanageable pain 3. gotten the client out of bed and into a chair 4. asked if the client was experiencing any discomfort

Answer 35

4

Question 36

the nurse is obtaining a pain history on two clients, one with chronic pain and another with acute pain. Which question is not as significant to ask of the client with acute pain? 1. where is the pain located 2. on a scale of 1 to 10 with 10 being the worst pain you have ever experienced in your life, how would you currently rate your pain 3. has the pain kept you from performing any of the things you normally do everyday 4. when did the pain begin

Answer 36

3

Question 37

the nurse is preparing to administer an analgesic to a client with terminal cancer who is experiencing severe pain. Which medication would be the best analgesic for this client? 1. morphine 2. demerol 3. percocet with acetaminophen 4. aspirin

Answer 37

1

Question 38

The nurse is providing preoperative teaching to the client about the use of patient- controlled analgesia. Which statement by the client informs the nurse that the teaching has been effective? 1. I have to be careful not to push the button too often or I will overdose myself 2. using a PCA will allow me to use more medication and relieve my pain better 3. Using a PCA will allow me to have a more constant level of pain control and i will need less medication 4. when I am asleep my wife can push the button to keep me comfortable

Answer 38

3

Question 39

when assessing a cleints pain following a motor vehicle crash the nurse learns that the client has some discomfort but would prefer not to take medication prior to her childs visit. Which would be an appropriate nursing action to increase the clients comfort level? 1. assist the client to get out of bed and into the bedside chair 2. assist the client to control her breathing 3. administer morphine sulfate IV push 4. Cancel visiting hours so the client may practice guided imagery

Answer 39

2