NUR 114 - FUNDAMENTALS EXAM 1 Questions and Answers
Question 1.
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.
Correct Answer: C. The nurse moves the patient table away from the nurse's
body when wiping it off after a meal.
Question 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? A. Incubation period B. Prodromal stage C.
Full stage of illness D. Convalescent period
Correct Answer: B. Prodromal
Question 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. A. The nurse is providing a bed bath for a patient. B. The nurse has visibly soiled
hands after changing the bedding of a patient. C. The nurse removes gloves when patient
care is completed. D. The nurse is inserting a urinary catheter for a female patient. E. The
nurse is assisting with a surgical placement of a cardiac stent. F. The nurse removes old
magazines from a patient's table.
Correct Answer: A. The nurse is providing a bed bath for a patient. F. The nurse
removes old magazines from a patient's table. D. The nurse is inserting a
urinary catheter for a female patient C. The nurse removes gloves when patient
care is completed
Question 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.
A. The nurse removes all jewelry including a platinum wedding band. B. The nurse washes
hands to one inch above the wrists. C. The nurse uses approximately two teaspoons of
liquid soap. D. The nurse keeps hands higher than elbows when placing under faucet. E.
The nurse uses friction motion when washing for at least 15 seconds. F. The nurse rinses
thoroughly with water flowing toward fingertips.
Correct Answer: all except D (keeping hands higher than elbows under faucet;
dirty water would run down your arms) and A
,Question 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: 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 inch of the sterile field as contaminated.
Correct Answer: D. Consider the outer 1 inch of the sterile fielda s contaminated
Question 6.
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
Correct Answer: D. all patients receiving care in hospitals
Question 7.
In addition to standard precautions, the nurse would initiate droplet precautions for which
patients? Select all that apply. A. A patient diagnosed with rubella B. A patient diagnosed
with diptheria 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
Correct Answer: A. A patient diagnosed with rubella B. A patient diagnosed with
diptheria F. An infant diagnosed with adenovirus infection
Question 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 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.
Correct Answer: C. Discard the supplies and prepare a new sterile field with
another person holding the patient's hand.
Question 9.
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 inches (10 to 15 cm).
Correct Answer: D. Pour the solution from a height of 4 to 6 inches (10 to 15
cm).
, Question 10.
A nurse is finished with patient care. How would the nurse remove PPE when leaving the
room? A. Remove gown, goggles, mask, gloves, and exit the room. B. Remove gloves,
perform hand hygiene, then remove gown, mask, and goggles. C. Untie gown waiststrings,
remove gloves, goggles, gown, mask; perform hand hygiene. D. Remove goggles, mask,
gloves, gown, and perform hand hygiene.
Correct Answer: C. Untie gown waiststrings, remove gloves, goggles, gown,
mask; perform hand hygiene.
Question 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? 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
postexposure prophylaxis at appropriate time. D. Set up counseling sessions regarding
safe practice to protect self.
Correct Answer: B. Wash the exposed area with warm water and soap.
Question 12.
The nurse assesses patients to determine their risk for health care-associated infections.
Which hospitalized patient is 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
Correct Answer: C. A 65-year-old patient who has an indwelling urinary catheter
in place
Question 13.
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an
open reddened area over his sacrum. What is a priority nursing diagnosis for this patient?
A. Imbalanced Nutrition: More Than Body Requirements related to immobility B. Impaired
Physical Mobility related to pain and discomfort C. Chronic Pain related to immobility D.
Risk for Infection related to altered skin integrity
Correct Answer: D. Risk for Infection related to altered skin integrity
Question 14.
A nurse teaches a patient at home to use clean technique when changing a wound
dressing. This practice is considered: A. The nurse's preference B. Safe for the home
setting C. Unethical behavior D. Grossly negligent
Correct Answer: B. Safe for the home setting
Question 15.
Question 1.
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.
Correct Answer: C. The nurse moves the patient table away from the nurse's
body when wiping it off after a meal.
Question 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? A. Incubation period B. Prodromal stage C.
Full stage of illness D. Convalescent period
Correct Answer: B. Prodromal
Question 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. A. The nurse is providing a bed bath for a patient. B. The nurse has visibly soiled
hands after changing the bedding of a patient. C. The nurse removes gloves when patient
care is completed. D. The nurse is inserting a urinary catheter for a female patient. E. The
nurse is assisting with a surgical placement of a cardiac stent. F. The nurse removes old
magazines from a patient's table.
Correct Answer: A. The nurse is providing a bed bath for a patient. F. The nurse
removes old magazines from a patient's table. D. The nurse is inserting a
urinary catheter for a female patient C. The nurse removes gloves when patient
care is completed
Question 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.
A. The nurse removes all jewelry including a platinum wedding band. B. The nurse washes
hands to one inch above the wrists. C. The nurse uses approximately two teaspoons of
liquid soap. D. The nurse keeps hands higher than elbows when placing under faucet. E.
The nurse uses friction motion when washing for at least 15 seconds. F. The nurse rinses
thoroughly with water flowing toward fingertips.
Correct Answer: all except D (keeping hands higher than elbows under faucet;
dirty water would run down your arms) and A
,Question 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: 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 inch of the sterile field as contaminated.
Correct Answer: D. Consider the outer 1 inch of the sterile fielda s contaminated
Question 6.
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
Correct Answer: D. all patients receiving care in hospitals
Question 7.
In addition to standard precautions, the nurse would initiate droplet precautions for which
patients? Select all that apply. A. A patient diagnosed with rubella B. A patient diagnosed
with diptheria 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
Correct Answer: A. A patient diagnosed with rubella B. A patient diagnosed with
diptheria F. An infant diagnosed with adenovirus infection
Question 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 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.
Correct Answer: C. Discard the supplies and prepare a new sterile field with
another person holding the patient's hand.
Question 9.
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 inches (10 to 15 cm).
Correct Answer: D. Pour the solution from a height of 4 to 6 inches (10 to 15
cm).
, Question 10.
A nurse is finished with patient care. How would the nurse remove PPE when leaving the
room? A. Remove gown, goggles, mask, gloves, and exit the room. B. Remove gloves,
perform hand hygiene, then remove gown, mask, and goggles. C. Untie gown waiststrings,
remove gloves, goggles, gown, mask; perform hand hygiene. D. Remove goggles, mask,
gloves, gown, and perform hand hygiene.
Correct Answer: C. Untie gown waiststrings, remove gloves, goggles, gown,
mask; perform hand hygiene.
Question 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? 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
postexposure prophylaxis at appropriate time. D. Set up counseling sessions regarding
safe practice to protect self.
Correct Answer: B. Wash the exposed area with warm water and soap.
Question 12.
The nurse assesses patients to determine their risk for health care-associated infections.
Which hospitalized patient is 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
Correct Answer: C. A 65-year-old patient who has an indwelling urinary catheter
in place
Question 13.
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an
open reddened area over his sacrum. What is a priority nursing diagnosis for this patient?
A. Imbalanced Nutrition: More Than Body Requirements related to immobility B. Impaired
Physical Mobility related to pain and discomfort C. Chronic Pain related to immobility D.
Risk for Infection related to altered skin integrity
Correct Answer: D. Risk for Infection related to altered skin integrity
Question 14.
A nurse teaches a patient at home to use clean technique when changing a wound
dressing. This practice is considered: A. The nurse's preference B. Safe for the home
setting C. Unethical behavior D. Grossly negligent
Correct Answer: B. Safe for the home setting
Question 15.
