Portage Learning
1 MAXE · 132 SRUN
★ ★
NURS 231 — Exam 1: Fundamentals of Nursing
P
TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
EST. 1972
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NURS 231 Exam 1 — Fundamentals of
Nursing
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NURS 231 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE Portage Learning NURS 231 Exam
1 BSU
TOTAL QUESTIONS 80 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Infection control, asepsis, hygiene, safety, body mechanics, nutrition, elimination, and mobility are all
testable content.
▸ Chain of infection, PPE, positioning, and therapeutic diets are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current nursing practice standards.
, SECTION I — FUNDAMENTALS OF NURSING:
Questions 1 – 80
COMPREHENSIVE REVIEW
1. Explain the chain of infection.
A. Infectious agent, reservoir, portal of exit, means of transmission, portal of entry,
susceptible host
B. Pathogen, host, environment, transmission
C. Agent, host, vector, transmission
D. Source, transmission, infection, disease
CORRECT ANSWER A — Infectious agent, reservoir, portal of exit, means of transmission, portal
of entry, susceptible host
RATIONALE The chain of infection includes: Infectious agent (bacteria, viruses, fungi),
Reservoir (natural habitat of the organism), Portal of exit (point of escape), Means
of transmission (direct contact, indirect contact, airborne), Portal of entry (point
at which organisms enter a new host), and Susceptible host (must overcome host
defenses). Breaking any link prevents infection.
2. Describe normal defense mechanisms of the body.
A. Skin (barrier, normal flora), Mouth (saliva, normal flora), Eyes (tears, blinking), Respiratory
tract (cilia, macrophages, mucus), Urinary tract (pH, flushing action), GI tract (acidity,
peristalsis, normal flora), Vagina (normal flora, low pH)
B. Only skin and mucous membranes
C. Only the immune system
D. Only white blood cells
CORRECT ANSWER A — Skin (barrier, normal flora), Mouth (saliva, normal flora), Eyes (tears,
blinking), Respiratory tract (cilia, macrophages, mucus), Urinary tract (pH,
flushing action), GI tract (acidity, peristalsis, normal flora), Vagina (normal
flora, low pH)
RATIONALE Normal defense mechanisms include: Skin as a barrier with normal flora; Mouth
with saliva and normal flora; Eyes with tears and blinking; Respiratory tract with
cilia, macrophages, and mucus; Urinary tract with pH and flushing action; GI tract
with acidity, peristalsis, and normal flora; Vagina with normal flora and low pH.
,3. What are nursing interventions used to break the chain of infection?
A. Hand hygiene with soap and water, hand hygiene with alcohol-based hand sanitizer
B. Only wearing gloves
C. Only wearing masks
D. Only sterilizing equipment
CORRECT ANSWER A — Hand hygiene with soap and water, hand hygiene with alcohol-based
hand sanitizer
RATIONALE Nursing interventions to break the chain of infection include hand hygiene with
soap and water, and hand hygiene with alcohol-based hand sanitizer. Hand
hygiene is the single most important intervention to prevent the spread of
infection.
4. Identify situations in which hand hygiene is indicated with soap and water versus alcohol-
based hand sanitizer.
A. Soap and water: visibly dirty hands, blood/body fluid exposure, after toilet use, C-diff
exposure; Alcohol sanitizer: not visibly soiled, before/after patient contact, when moving
from contaminated to clean areas
B. Soap and water is always preferred
C. Alcohol sanitizer is always preferred
D. Only soap and water should be used in healthcare
CORRECT ANSWER A — Soap and water: visibly dirty hands, blood/body fluid exposure, after
toilet use, C-diff exposure; Alcohol sanitizer: not visibly soiled, before/after
patient contact, when moving from contaminated to clean areas
RATIONALE Hand hygiene with soap and water should be done when hands are visibly dirty,
soiled with blood or bodily fluids, before eating and after using the toilet,
exposure to spore organisms like C-diff, and after contact with bodily fluids.
Alcohol-based hand sanitizer is used if hands are not visibly soiled, before/after
patient contact, when moving from contaminated areas to clean areas, and
before caring for immunosuppressed patients.
, 5. Differentiate between medical and surgical asepsis.
A. Medical asepsis is clean technique; surgical asepsis is sterile technique used in OR, labor
and delivery, diagnostic testing, and bedside procedures
B. Medical asepsis is sterile; surgical asepsis is clean
C. They are the same thing
D. Medical asepsis is only used in surgery
CORRECT ANSWER A — Medical asepsis is clean technique; surgical asepsis is sterile technique
used in OR, labor and delivery, diagnostic testing, and bedside procedures
RATIONALE Medical asepsis is referred to as the clean technique, while surgical asepsis is
referred to as the sterile technique. Surgical asepsis should be used in operating
rooms, labor and delivery areas, certain diagnostic testing areas, and the patient's
bedside for sterile procedures.
6. Describe signs and symptoms of acute/local infection and systemic infection.
A. Acute/local: redness, swelling, heat, pain, loss of function; Systemic: fever (primary sign),
nausea/vomiting, malaise, possible confusion, possible decreased LOC
B. Acute: fever; Systemic: redness and swelling
C. Both are the same
D. Acute: pain only; Systemic: fever only
CORRECT ANSWER A — Acute/local: redness, swelling, heat, pain, loss of function; Systemic:
fever (primary sign), nausea/vomiting, malaise, possible confusion,
possible decreased LOC
RATIONALE Signs of acute/local infection are redness, swelling, heat, pain, and loss of
function. Signs of systemic infection are fever (primary sign), nausea/vomiting,
malaise, possible confusion, and possible decreased level of consciousness.
1 MAXE · 132 SRUN
★ ★
NURS 231 — Exam 1: Fundamentals of Nursing
P
TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
EST. 1972
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NURS 231 Exam 1 — Fundamentals of
Nursing
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NURS 231 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE Portage Learning NURS 231 Exam
1 BSU
TOTAL QUESTIONS 80 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Infection control, asepsis, hygiene, safety, body mechanics, nutrition, elimination, and mobility are all
testable content.
▸ Chain of infection, PPE, positioning, and therapeutic diets are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current nursing practice standards.
, SECTION I — FUNDAMENTALS OF NURSING:
Questions 1 – 80
COMPREHENSIVE REVIEW
1. Explain the chain of infection.
A. Infectious agent, reservoir, portal of exit, means of transmission, portal of entry,
susceptible host
B. Pathogen, host, environment, transmission
C. Agent, host, vector, transmission
D. Source, transmission, infection, disease
CORRECT ANSWER A — Infectious agent, reservoir, portal of exit, means of transmission, portal
of entry, susceptible host
RATIONALE The chain of infection includes: Infectious agent (bacteria, viruses, fungi),
Reservoir (natural habitat of the organism), Portal of exit (point of escape), Means
of transmission (direct contact, indirect contact, airborne), Portal of entry (point
at which organisms enter a new host), and Susceptible host (must overcome host
defenses). Breaking any link prevents infection.
2. Describe normal defense mechanisms of the body.
A. Skin (barrier, normal flora), Mouth (saliva, normal flora), Eyes (tears, blinking), Respiratory
tract (cilia, macrophages, mucus), Urinary tract (pH, flushing action), GI tract (acidity,
peristalsis, normal flora), Vagina (normal flora, low pH)
B. Only skin and mucous membranes
C. Only the immune system
D. Only white blood cells
CORRECT ANSWER A — Skin (barrier, normal flora), Mouth (saliva, normal flora), Eyes (tears,
blinking), Respiratory tract (cilia, macrophages, mucus), Urinary tract (pH,
flushing action), GI tract (acidity, peristalsis, normal flora), Vagina (normal
flora, low pH)
RATIONALE Normal defense mechanisms include: Skin as a barrier with normal flora; Mouth
with saliva and normal flora; Eyes with tears and blinking; Respiratory tract with
cilia, macrophages, and mucus; Urinary tract with pH and flushing action; GI tract
with acidity, peristalsis, and normal flora; Vagina with normal flora and low pH.
,3. What are nursing interventions used to break the chain of infection?
A. Hand hygiene with soap and water, hand hygiene with alcohol-based hand sanitizer
B. Only wearing gloves
C. Only wearing masks
D. Only sterilizing equipment
CORRECT ANSWER A — Hand hygiene with soap and water, hand hygiene with alcohol-based
hand sanitizer
RATIONALE Nursing interventions to break the chain of infection include hand hygiene with
soap and water, and hand hygiene with alcohol-based hand sanitizer. Hand
hygiene is the single most important intervention to prevent the spread of
infection.
4. Identify situations in which hand hygiene is indicated with soap and water versus alcohol-
based hand sanitizer.
A. Soap and water: visibly dirty hands, blood/body fluid exposure, after toilet use, C-diff
exposure; Alcohol sanitizer: not visibly soiled, before/after patient contact, when moving
from contaminated to clean areas
B. Soap and water is always preferred
C. Alcohol sanitizer is always preferred
D. Only soap and water should be used in healthcare
CORRECT ANSWER A — Soap and water: visibly dirty hands, blood/body fluid exposure, after
toilet use, C-diff exposure; Alcohol sanitizer: not visibly soiled, before/after
patient contact, when moving from contaminated to clean areas
RATIONALE Hand hygiene with soap and water should be done when hands are visibly dirty,
soiled with blood or bodily fluids, before eating and after using the toilet,
exposure to spore organisms like C-diff, and after contact with bodily fluids.
Alcohol-based hand sanitizer is used if hands are not visibly soiled, before/after
patient contact, when moving from contaminated areas to clean areas, and
before caring for immunosuppressed patients.
, 5. Differentiate between medical and surgical asepsis.
A. Medical asepsis is clean technique; surgical asepsis is sterile technique used in OR, labor
and delivery, diagnostic testing, and bedside procedures
B. Medical asepsis is sterile; surgical asepsis is clean
C. They are the same thing
D. Medical asepsis is only used in surgery
CORRECT ANSWER A — Medical asepsis is clean technique; surgical asepsis is sterile technique
used in OR, labor and delivery, diagnostic testing, and bedside procedures
RATIONALE Medical asepsis is referred to as the clean technique, while surgical asepsis is
referred to as the sterile technique. Surgical asepsis should be used in operating
rooms, labor and delivery areas, certain diagnostic testing areas, and the patient's
bedside for sterile procedures.
6. Describe signs and symptoms of acute/local infection and systemic infection.
A. Acute/local: redness, swelling, heat, pain, loss of function; Systemic: fever (primary sign),
nausea/vomiting, malaise, possible confusion, possible decreased LOC
B. Acute: fever; Systemic: redness and swelling
C. Both are the same
D. Acute: pain only; Systemic: fever only
CORRECT ANSWER A — Acute/local: redness, swelling, heat, pain, loss of function; Systemic:
fever (primary sign), nausea/vomiting, malaise, possible confusion,
possible decreased LOC
RATIONALE Signs of acute/local infection are redness, swelling, heat, pain, and loss of
function. Signs of systemic infection are fever (primary sign), nausea/vomiting,
malaise, possible confusion, and possible decreased level of consciousness.
