QUESTIONS AND ANSWERS
ALREADY PASSED
"The nurse understands that which statement is correct regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
b. Healthy adults breathe between 12 and 20 times a minute.
c. A compensatory response to a fever is to breathe at a slower rate.
d. An increase in intracranial pressure results in an increased rate. - CORRECT ANSWER=> b"
"The nurse is caring for a patient who has a blood pressure of 184/110. An hour after administering an
antihypertensive medication, the nurse returns to recheck the blood pressure, only to find the patient in
the chair pale, sweaty, and feeling faint. Which is the expected explanation for the nurse's observations?
a. The blood pressure is 184/110; the medication has not had an effect.
b. The blood pressure is 118/76; the sudden drop has caused the signs.
c. The blood pressure is 174/96; the medication has made the patient sick.
d. The blood pressure is 130/82; the symptoms are from another cause. - CORRECT ANSWER=> b"
"It is 6 a.m. and the unlicensed assistive personnel reports to the nurse that the patient has a
temperature of 96.7° F (35.9° C) tympanic. Which factor explains this reading?
a. The patient's room is cold.
b. The patient was drinking cold water.
c. The patient is exhibiting a normal circadian rhythm.
d. The patient just completed a warm shower. - CORRECT ANSWER=> c"
"The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus
aureus located in her incision. What transmission-based precautions will the nurse implement for the
patient?
a. Private room
b. Private, negative-airflow room
c. Mask worn by the staff when entering the room
d. Mask worn by the staff and the patient when leaving the patient's room - CORRECT ANSWER=> a"
"A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or
isolation does the nurse know is appropriate for this patient?
a. Airborne precautions
b. Droplet precautions
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,c. Contact precautions
d. Protective isolation - CORRECT ANSWER=> c"
"In which situations does the nurse wear clean gloves as part of standard precautions? (Select all that
apply.)
a. In the care of a patient diagnosed with an infectious process
b. When the patient is diaphoretic
c. During perineal care of each individual under treatment in the facility
d. In the presence of urine or stool
e. When taking the patient's blood pressure - CORRECT ANSWER=> a, c, d"
"The nurse is providing patient education on infection prevention. Which definition of an infection does
the nurse use as a teaching point?
a. An illness resulting from living in an unclean environment
b. A result of lack of knowledge about food preparation
c. A disease resulting from pathogens in or on the body
d. An acute or chronic illness resulting from traumatic injury - CORRECT ANSWER=> c"
"The nurse is caring for a patient who had abdominal surgery and has developed an infection in the
wound while hospitalized. Which agent is most likely the cause of the infection?
a. Virus
b. Bacterium
c. Fungus
d. Spore - CORRECT ANSWER=> b"
"A nurse is preparing to change a sterile dressing and has donned a pair of sterile gloves. To maintain
surgical asepsis, what else must the nurse do?
a. Keep the amount of splashes on the sterile field to a minimum.
b. If a sneeze is imminent, cover the nose and mouth with a gloved hand.
c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing.
d. Regard the outer 1 inch of the sterile field as contaminated. - CORRECT ANSWER=> d"
"What is the proper order of removal of soiled personal protective equipment when the nurse leaves the
patient's room?
a. Gown, goggles, mask, gloves, and exit the room
b. Gloves, wash hands, remove gown, mask, and wash hands
c. Gloves, goggles, gown, mask, and wash hands
d. Goggles, mask, gloves, gown, and wash hands - CORRECT ANSWER=> c"
"Of the following hospitalized patients, who is most at risk for acquiring a health care-associated
infection?
a. A 60-year-old who smokes two packs of cigarettes per day
b. A 40-year-old who has an indwelling urinary catheter in place
c. A 65-year-old who is a vegetarian and slightly underweight
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, d. A 60-year-old who has a white blood cell count of 6000 - CORRECT ANSWER=> b"
"A patient develops food poisoning from contaminated food. What is the means of transmission for the
infectious organism?
a. Direct contact
b. Vector
c. Vehicle
d. Airborne - CORRECT ANSWER=> c"
"Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site
infection? (Select all that apply.)
a. Thick, white drainage in the Jackson-Pratt tubing
b. Redness or warmth at the affected site
c. Purulent drainage at the incision sited.
d. Temperature 100.4 F
e. Tenderness and localized pain
f. Wound with well-approximated edges
g. Purulent drainage at the incision site - CORRECT ANSWER=> a, b, c, d, e, g"
"On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that,
when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse?
a. The presence of an infection in the area
b. The presence of a stage 1 pressure injury
c. An allergic reaction to the sheets
d. The need to apply a cold compress to reduce inflammation - CORRECT ANSWER=> b"
"Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his
abdominal wound. An increase in amount of drainage from the wound is seen, and further examination
shows that the sutured incision is now partially open, with tissue protruding from the wound. Which are
the priority nursing interventions? (Select all that apply.)
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze
c. Apply a binder to pull the wound edges together and provide support to the edges.
d. Notify the physician.
e. Allow the area to be exposed to air until all the drainage has stopped. - CORRECT ANSWER=> b, d"
"Which features are characteristic of a closed drainage system, such as a Jackson-Pratt (JP) drain? (Select
all that apply.)
a. Works by gravity
b. Provides for early discharge
c. Usually is inserted in surgery
d. Reduces the amount of antibiotics required
e. Allows for accurate measurement of wound drainage - CORRECT ANSWER=> c, e"
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