NURA 303 Chapter 24 Test Questions
and Answers
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 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?
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 waist strings, remove gloves, goggles, gown, mask; perform hand
hygiene
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.
and Answers
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 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?
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 waist strings, remove gloves, goggles, gown, mask; perform hand
hygiene
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.
