NURA 303 Final Exam 2 Questions All
Solved Correct.
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 - Answer 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.
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 - Answer 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.
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
,invasive procedure; if moving from a contaminated body site to a clean body site; and after
contact with objects contaminated by the patient. Keep in mind that handrubs are not
appropriate for use with C. difficile infection.
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 - Answer b, c, 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 20 seconds, washing to 1 in above the wrists with a
friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward
fingertips.
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 - Answer 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 gloves.
Forceps soaked in disinfectant are not considered sterile.
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 - Answer d. Standard precautions apply to all patients
receiving care in hospitals, regardless of their diagnosis or possible infection status. These
,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 - Answer a, b, f. Rubella, diphtheria, and
adenovirus infection are illnesses transmitted by large-particle droplets and require droplet
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.
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 - Answer 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.
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) - Answer 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 in (10 to 15 cm).
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
, D. Remove goggles, mask, gloves, and gown, and perform hand hygiene - Answer 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, followed by the goggles, gown, and mask, and hands should be
washed thoroughly after the equipment has been removed and before leaving the room.
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 - Answer 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 PEP, and attend counseling
sessions regarding safe practice to protect self and others.
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 - Answer c. Indwelling
urinary catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood
cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.
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 - Answer d. The priority risk factor in this situation is the possibility of an infection
developing in the open skin area. The other risk factors may be potential problems for this
patient and may also require nursing interventions after the first diagnosis is addressed.
Solved Correct.
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 - Answer 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.
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 - Answer 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.
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
,invasive procedure; if moving from a contaminated body site to a clean body site; and after
contact with objects contaminated by the patient. Keep in mind that handrubs are not
appropriate for use with C. difficile infection.
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 - Answer b, c, 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 20 seconds, washing to 1 in above the wrists with a
friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward
fingertips.
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 - Answer 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 gloves.
Forceps soaked in disinfectant are not considered sterile.
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 - Answer d. Standard precautions apply to all patients
receiving care in hospitals, regardless of their diagnosis or possible infection status. These
,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 - Answer a, b, f. Rubella, diphtheria, and
adenovirus infection are illnesses transmitted by large-particle droplets and require droplet
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.
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 - Answer 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.
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) - Answer 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 in (10 to 15 cm).
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room?
, D. Remove goggles, mask, gloves, and gown, and perform hand hygiene - Answer 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, followed by the goggles, gown, and mask, and hands should be
washed thoroughly after the equipment has been removed and before leaving the room.
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 - Answer 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 PEP, and attend counseling
sessions regarding safe practice to protect self and others.
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 - Answer c. Indwelling
urinary catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood
cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.
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 - Answer d. The priority risk factor in this situation is the possibility of an infection
developing in the open skin area. The other risk factors may be potential problems for this
patient and may also require nursing interventions after the first diagnosis is addressed.
