Fundamen tals of Nursing N192 Exam #1 Questions With Complete Solutions 1. A nurse is following the principles of medical asepsis when performing patient care i n a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? hhCorrect Answers hh1. c. According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas. 2. 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? hhCorrect Answers hh2. b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low -grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of illness, before disappearing by the convalescent period. 3. 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. hhCorrect Answers hh3. a, c, d, f. It is recommended to use an alcohol -based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the pati ent. 4. 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. hhCorrect Answers hh4. b, e, f. Proper hand hygiene includes removing jewelry with the exception of a plain wedding band, wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 15 seconds, washing to one inch above the wrists wi th a friction motion for at least 15 seconds, and rinsing thoroughly with water flowing toward fingertips. 5. 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. The nurse must: hhCorrect Answers hh5. d. Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gl oves. Forceps soaked in disinfectant are not considered sterile. 6. The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? hhCorrect Answers hh6. d. Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes. 7. In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. hhCorrect Answers hh7. a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large -particle droplets and require dropl et precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles, for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug -
resistant organism (MDRO), such as MRSA. 8. 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 pati ent accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? hhCorrect Answers hh8. c. If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening. 9. A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action w hen performing this task? hhCorrect Answers hh9. d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). 10. A nurse is finished with patient care. How would the nurse remove PPE when leaving t he room? hhCorrect Answers hh10. c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, follo wed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room. 11. 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 priority action of the nurse following the exposure? hhCorrect Answers hh11. b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to postexposure prophylaxis, and attend counseling sessions regarding safe practice to protect self and others. 12. The nurse assesses pat ients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? hhCorrect Answers hh12.
resistant organism (MDRO), such as MRSA. 8. 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 pati ent accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? hhCorrect Answers hh8. c. If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening. 9. A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action w hen performing this task? hhCorrect Answers hh9. d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). 10. A nurse is finished with patient care. How would the nurse remove PPE when leaving t he room? hhCorrect Answers hh10. c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, follo wed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room. 11. 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 priority action of the nurse following the exposure? hhCorrect Answers hh11. b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to postexposure prophylaxis, and attend counseling sessions regarding safe practice to protect self and others. 12. The nurse assesses pat ients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? hhCorrect Answers hh12.
